Volunteer Application

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Years at Current Address*
Phone*
Email*
Enter Email Confirm Email
Membership Request*
Have you ever been convicted or plead guilty to a felony, misdemeanor, arson charge, or a to a reduction of any one of these offenses, which was not terminated in your favor?*
- Yes
- No
Please explain
Physical exam consent*
OSHA regulations require that you pass a physical exam before becoming an interior structural firefighter. All RLFD members are required to have a medical exam, provided free by our medical provider. Are you willing to undergo such an exam?
- Yes
- No
Are you currently employed?*
- Yes
- No
Employer's Name
Supervisor's Name
Supervisor's Phone
Do you have any previous emergency service experience?*
- Yes
- No
What agency?
Contact in that agency
Years of experience
Positions held
References
Other than members of this organization, list 3 personal references who have known you for at least 3 years.
Reference #1 Name*
First Last
Reference #1 Phone*
Reference #2 Name*
First Last
Reference #2 Phone*
Reference #3 Name*
First Last
Reference #3 Phone*
Email
This field is for validation purposes and should be left unchanged.

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Round Lake