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GILES COUNTY FIRE AND RESCUE
120 JIMMY SUGGS DR.
PULASKI, TN 38478
Application for Membership
Date
Name
(Last) (First) (M.I.)
Street Address City State ZIP
How long at this address?
Home Phone
Business
Other
Previous Address
How long at previous address?
D.L. #
Person to notify in case of emergency?
phone
SS#
Education / Highest grade completed
Employer
Name
City
Years
Personal References: Name City phone #
1.
2.
3.
4.
Do you have reliable transportation?
Yes No
When are you available for calls or meetings? Day
Night
Other organizations you belong to
:
Do you give Giles County Fire and Rescue permission to check your driving record? If so, please
sign below. Give your date of birth and list any violations within the last 4 years.
Signature
Date of Birth
Offenses /Date:
Do you have any physical limitations that would require alteration or restriction on your activities
in the squad?
Yes
No If yes,
please explain
List any special skills you feel could contribute to the squad .
Current level of certification: circle all that apply: EMT (level
) BRT (level ) SAR (level )
Briefly explain why you wish to become a member of the Giles County Fire and Rescue Squad:
Certification
This is to certify that, if accepted, I will abide by the Constitution and By-Laws of the Giles County
Fire and Rescue Squad as long as I shall remain a member. I further certify that under penalty of
being discharged from the membership, that the questions I have answered on this form are true
to the best of my knowledge.
Signed Date
DO NOT WRITE BELOW THIS LINE
__________________________________________________________________________________
Membership committee recommendation Yes
No
Date
Remarks :
Membership vote: Members Present
Approved
Disapproved
Date
Remarks
Signed:
Chief Asst. Chief
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