Membership Application

Kenova Fire Department

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Application for Membership

I give my permission to the Kenova Fire Department and its representatives to conduct a complete background check. I also understand any misrepresentation on this form will be sufficient cause for immediate termination.

	I agree to the above statement
Email Address: *
Todays Date:
Type of Membership requested Fire, EMS, or Both: *
First Name: *
Middle Name:
Last Name: *
DOB:
Gender:
Address: *
City: *
State: *
Zip: *
Drivers License # and State:
Home Phone #:
Cell #:
EDUCATION
High School you attended:
Did you Graduate High School?: *
If not do you have a GED?: *
Do you have any Firefighting or EMS experience?:
WV EMT/Paramedic ID #:
National #:
Current employer, and employer contact information:
Have you ever been a member of Kenova Fire? If so explain:
Why do you want to become a member?:
Have you ever been convicted of a crime?:
If so explain:
List 3	References:
(1) Name:
Address:
Phone:
(2) Name:
Address:
Phone:
(3) Name:
Address:
Phone:
Security Code: *