Form Center

2. 
3. 
   
   FRANKLIN COUNTY FIRE & EMS
   50 CLAIBORNE AVE.
   ROCKY MOUNT, VA 24151
5. Making false statements on this application will disqualify this application
   and you from applying within our agency for a period up to one year!

   Please Note: Virginia Office of EMS (OEMS) requires all applicants after July 1, 2013 to be fingerprinted for their background check

7. Last Name *
8. First Name *
9. Middle Name or Initial*
10. Birth Date*
    Birth Date
12. Street Address *
13. City*
14. State*
15. Zip*
17. Home Phone*
18. Cell Phone*
19. E-Mail Address*
21. Gender *
    -- Select One --Male Female
22. Race*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderTwo or More Races White
24. Do you have a valid "Virginia" driver’s license?*

    1. Yes
    2. No
25. Attach Virginia License*
26. Please submit a copy of your driver’s transcript from the driver’s license issuing state.
28. Have you ever been convicted of any law violation including a misdemeanor or felony?*

    1. Yes
    2. No
29. If Yes, Explain
31. Do you have any pending criminal charges?*

    1. Yes
    2. No
32. If Yes, Explain
34. Have you ever been convicted of any traffic violation?*

    1. Yes
    2. No
35. If Yes, Explain
37. Previous Emergency Services Experience*
39. Certification Levels & Training
40. Upload a copy of certification certificate
42. List any applicable physical, mental or emotional disadvantages*
43. Please choose the agency that you would like to volunteer with.*
    -- Select One --Boones Mill Fire Department Burnt Chimney Fire Department Callaway Fire Department Callaway RescueChaplain Response Team FCDPS CadreFerrum Fire DepartmentFork Mountain Fire Department Fork Mountain Rescue Franklin County RescueGlade Hill Fire Department Henry Fire Department Red Valley Rescue Scruggs Fire Department Scruggs Rescue Snow Creek Fire Department Snow Creek Rescue Special Operations Team
45. Are you under the age of 18?*

    1. Yes
    2. No
46. Parent Liability Form
    Parent Liability Form (PDF)

    You MUST print, complete and submit the Parent Liability Form before your application will be processed.

48. BY TYPING or SIGNING YOUR NAME, YOU ARE CERTIFYING THAT YOU HAVE READ AND AGREE WITH THE FOLLOWING STATEMENT IN ITS ENTIRETY.*

    I agree that my typed name on this document is the legally binding equivalent to my handwritten signature, and that the information provided is true and accurate to the best of my knowledge and is a complete record. I authorize Franklin County Fire & EMS to investigate my criminal and motor vehicle operation background to verify the information is correct.

    1. I agree.
50. Electronic Signature*
51. Date*
    Date
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field