Westmoreland County Volunteer Rescue Squad
PO Box 37
Mt. Holly, VA 22524
Phone: 804 472-2632 Fax: 804 472-5437
MEMBERSHIP APPLICATION
Type of Application: Ambulance Crew [ ] Administrative [ ] Auxiliary [ ]
Name: ____________________________________________________________________________
Address: __________________________________________________________________________
City: ____________________________________ State: ____ Zip Code: ______________
Date of Birth: Month: ___ Day: ___ Year: ________ Social Security No. _____ - ____ - ________
Male:____ Female:____ Race: _____________________
Contact Phone Number: _________________________ Work Phone:_________________
VA Drivers License No.: ______________________ CDL: Y/N ___
Restrictions: __________________________________________________________________
EDUCATION & CERTIFICATIONS
High School Grad: Y/N___ School Name: _________________________ Year Graduated ________
College/University: Y/N___ School Name: ________________________________________________
Degree: Y/N ___ Degree:__________________________________ Number Years:_____
Technical School: Y/N___ Graduate: Y/N ___ Course:_______________________________
Military: Not Applicable:__ Air Force: __ Army: __ Navy: __ Marine: __ Coast Guard: __
Total Years Military Service: _____
EMS Certifications: None:___ EMT: B:__ E: __ I: __ P: __ National Registry Y/N___
EVOC: Y/N___ Class: _____ From:_________________________________________________
EMS Certification Expires: Month: ___ Day: ___ Year: ______
Other Fire/Rescue/Police Certifications: __________________________________________
____________________________________________________________________________
PERSONAL REFERNCES (3 Required):
1. Name: ________________________________________ Phone No.: _________________
City & State: _______________________________________________________________
2. Name: ________________________________________ Phone No.: _________________
City & State: _______________________________________________________________
3. Name: _________________________________________ Phone No.: ________________
City & State: _______________________________________________________________
All applicants are required by the Commonwealth of Virginia to undergo a background
investigation. Therefore, it is necessary that you indicate whether you have ever been
convicted of a felony. Have you ever been convicted of a crime other than a traffic summons?
YES ____ NO_____
If the answer is YES. Provide an explanation in the space provided below:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I certify that the information provided herein is true and accurate as of the data of this
application. I am over ____/under____ the age of 18 years.
____________________________________________________ _______________________
Signature Date
For Junior Membership Only:
The Applicant is under the age of 18 and I am the legal Parent or Guardian of the Applicant. I
approve the Applicant's desire to be a member of the Westmoreland County Volunteer Rescue
Squad and my signature made here on is my approval of that application.
___________________________________________________ ________________________
Signature Date
Printed Name:__________________________________________________________________
Address:______________________________________________________________________
______________________________________________________________________________
Contact Phone Number:_____________________________