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2. Volunteer Preference*
   -- Select One --FireEMSFire & EMS
3. Department Interested in Joining*
   -- Select One --Blue RidgeBotetourt CountyBuchananEagle RockFincastleGlen WiltonRead Mountain - 18+ OnlyTroutville
5. First Name*
6. Middle Name
7. Last Name*
9. Are you under 18 years of age?*

   1. Yes
   2. No
10. Date of Birth*
    Date of Birth
11. Parent/Guardian Name
12. Parent/Guardian Phone Number
14. Email Address*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Home Phone
23. Cell Phone
25. Gender*
    -- Select One --FemaleMale
26. Have you ever held a Virgina Driver's License*
    -- Select One --YesNo
28. Driver's License Number
30. Highest Education Obtained*
    -- Select One --Currently in High SchoolHigh School Diploma / GEDSome College2 Year College4 Year CollegeGraduate SchoolTrade School
34. Criminal History
36. Have you ever been convicted of a felony? *
    -- Select One --YesNo
38. Have you ever been a subject of a complaint regarding neglect of an animal, child, the elderly, or anyone in your care?*
    -- Select One --YesNo
40. Do you have any traffic violations in the last 3 years?*
    -- Select One --YesNo
42. If you answered yes to any of the previous questions please explain.
46. Experience
48. Have you been affiliated with any other fire and rescue organizations within the past 3 years?
    -- Select One --YesNo
50. What is your primary occupation?
    -- Select One --Accommodations / Food ServiceAdministrative / SupportAgricultureArt / Entertainment / RecreationConstructionEducational ServicesEmergency Medical ServiceFamily CareFinanceFire ServiceHealth CareInformation TechnologyManagementMilitaryProfessional / ScientificPublic AdministrationRetail TradeRetiredSelf EmployedStudentTransportation / WarehousingUnemployedOther
54. Please provide any previous fire departments or rescue organizations that you have been a member of
56. Department #1
58. Department #2
60. Department #3
64. References

    Please list name, address and home & work phone numbers.

66. Reference #1*
68. Reference #2*
70. Reference #3*
74. Acknowledgement
76. Please type your signature here:*
78. How did you hear about us?*
    -- Select One --EventFacebookTwitterReferred by IndividualLocal RestaurantFlyer, Brochure, or PostersSearch EngineStation VisitDirect MailSelect AnswerOther
80. If referred, who referred you?

82. BA criminal background check and DMV report is required for all volunteers. You will be contacted in person to give your social security number. By pressing the submit button below, I certify that I have completed this application to the best of my knowledge and ability.

    I certify that the above information is true, complete, and accurate. Falsification of information is grounds for dismissal. I also understand that I am giving permission to Botetourt County to run a criminal background check and DMV report.

Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field