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MAGNOLIA FIRE COMPANY
NEW MEMBERSHIP INTEREST FORM
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1. What is your full legal name?
Your answer
2. What is your date of birth?
MM
/
DD
/
YYYY
3. Where do you currently reside? (Town/City and State)
Your answer
4. What type of membership are you interested in?
CADET MEMBERSHIP (16 to 17 years of age)
ACTIVE FIREFIGHTER MEMBERSHIP (18 years of age)
DUTY CREW FIREFIGHTER MEMBERSHIP (18 years of age)
CONTRIBUTING MEMBERSHIP (18 years of age)
Clear selection
5. Do you have prior firefighting experience?
Yes
No
Not Applicable - Interest in Contributing Membership ONLY
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6. If you answered "Yes" to question #5, please provide details as to where you have experience as a firefighter. Please also provide your highest level of firefighting, rescue, emergency medical, and/or incident command system certifications.
Your answer
7. Have you ever been convicted of a crime?
Yes
No
Clear selection
8. If you answered "Yes" to question #7, please provide further information regarding your conviction of a crime.
Your answer
9. Have your driving privileges been suspended or revoked?
Yes
No
Clear selection
10. If you answered "Yes" to question #9, please provide further information regarding your suspension or revocation of driving privileges.
Your answer
11. What is your most current availability to participate within the department?
Morning
Afternoon
Evening
Overnight
Available during ALL or MULTIPLE times of the day
Clear selection
12. Please provide a valid email address where you can be reached for further communication.
Your answer
We sincerely thank you for your interest in joining the Magnolia Fire Company. Our department exists solely due to the dedication of motivated individuals, and we commend you for taking an interest in serving with us. Our membership personnel will contact you shortly to communicate with you further.
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