Membership ApplicationMembership Application First Name * Position of Interest Interior Structural Firefighter Fire Police Junior (Under 18) AdministrativeJoin Us Middle Initial * Last Name * Date of Birth (MM/DD/YYYY) * Age * Street Address * City, State, Zip * How long have you lived at this address? Home Phone Number * Cell Phone Number Place of Birth (City, State) * Email * Do you currently have any of these certifications? NJ Firefighter 1 NJ EMT-B NJ Paramedic New Jersey Fire Police Are You A United States Citizen? * YesNo Are You A Licensed Driver? YesNo If so, how long have you been driving the following?: Passenger Auto: Truck: Bus: Have You Had Any Accidents In The Last 3 Years? YesNo Have You Ever Had Your License Suspended? * YesNo Drivers License Number Select Licensed State New JerseyNew YorkOther: Please explain below. Other State? Select Drivers License Type Basic Drivers License (Class D)Commercial Drivers License (Class C)Commercial Drivers License (Class B)Commercial Drivers License (Class A) Have You Ever Been Convicted Of A Crime? * YesNo Will You Permit A Police Dept. Records Check? * YesNo Will You Consent To A Driving Abstract History Check? YesNo Signature * By checking this box you are declaring all the above answers are true to the best of my knowledge and belief. It is understood that any false statement on this application is sufficient cause for rejection or dismissal. Also if acceptance is obtained under this application, I further agree to comply with all orders, rules, and regulations of the Robertsville Vol. Fire Company. I further agree to submit to a physical examination. How did you hear about us? reCAPTCHA If you are human, leave this field blank. SubmitΔ