Greenland Volunteer Fire Department Application for Membership
Address: Soc. Sec. #:
Firefighter Only _____ EMT Only_____ Firefighter/EMT _____
Dispatcher______ Support Group _____
Company Name Address Phone Number
Experience and Education:
Please attach copies of all fire and/or EMT certifications, cards and licenses.
Fire and/or EMT Experience:
Home Phone: _________________________ Work Phone: __________________
I understand that as an active member of the Greenland Volunteer Fire Department I will be required to attend emergencies, drills, training, meetings and work details as well as follow the by-laws of the department.
By signing and submitting this application I attest that all statements above are true and authorize the Greenland Volunteer Fire Chief and/or their agents to verify. I give authorization for a motor vehicle and criminal background check to be performed, and any other background review deemed necessary.
Applicants signature: ________________________________ Date: _________________
To submit an application please include:
Mail your application, or drop it off at the department on
the second Tuesday of each month during our meeting at 7:00 pm.
Greenland Volunteer Fire Department – Chief
575 Portsmouth Avenue
Greenland NH 03840
Questions? Email the Fire Station at GVFD21@yahoo.com
Name of Applicant: ___________________________________
Date of Birth: ____________
The following medical information must be provided and signed by a medical doctor.
Height: ________________________ Weight: ____________
Vision: Left eye: ___________ Right eye: __________
Both eyes: __________ Corrected: __________
Blood Pressure: _____/______ Pulse: ________ Hearing:
General Physical Condition:
Physical Defects: ____________________________________________________________________
Relevant History: _______________________________________________________
I have examined _____________________________ and find him/her physically fit for performing the duties of a firefighter/EMT Responder.
Questions, comments, or suggestions?