Volunteer Membership Application - City of Salisbury MD

I respectfully submit my name for consideration as a volunteer member of the Salisbury Fire Department.
Today's Date:*
Name:*
First Middle Last
Current Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone Number*
Cell Phone Number:*
Work Phone Number*
Email Address:*
Former Address (If less than one year at current address)
Street Address Address Line 2 City State ZIP Code
Social Security Number:*
Date of Birth:*
Driver's License Information:*
License Number State Class
Current Employment Information:*
Employer Name Address Line City State ZIP Code
Have you ever been a member of another emergency services organization?*
- Yes
- No
If you answered "Yes", please provide the organization name and contact number of a contact person from this organization:*
Have you ever been arrested, convicted and/or received probation before judgement for any misdemeanor, felony, DWI, DUI, or motor vehicle violation other than parking tickets?*
- Yes
- No
If you answered "Yes", please provide the circumstances:
Please provide the contact information of three (3) personal references to whom you are not related by blood or marriage:*
Name
This field is for validation purposes and should be left unchanged.