Membership Application

Thank you for your interest in membership with the Leesburg Volunteer Fire Company.  Below, you'll find a short application form.   Please fill in each block as completely as possible.   When you've completed the form, click on the "Submit Information" button at the bottom of the page.   If you need to start over prior to sending the information, you can click on the "Clear All Fields" button.

When you submit the application, all your information will be sent to our membership committee who will then contact you to begin your membership process.   If you don't hear from them within 7 days of submitting your application, please send an email to webmaster@leesburgfire.org.   Again, thank you for your interest!

Membership Type:

Senior Member = age 18+, interested in running fire calls and receiving required training

Associate Member = age 18+, supporting member, assists with administration, fund raising, canteen

Junior Member = ages 16-17, interested in running fire calls and receiving required training, requires parental permission

Senior Associate Junior

First Name:      Last Name:

Date of Birth (mm/dd/yyyy):     

Current Address:

Street:

City:         State:      Zip:

Home Phone:      Best Contact Phone:     

Email address:

Previous Address (if at current less than 1 year):

Street:

City:         State:      Zip:

Employment / Education

Present Employer:

Employer Street:

City:         State:      Zip:

Phone:      Can we contact your employer? Yes No

References: (Please list two character references NOT currently members of the Leesburg Volunteer Fire Company)

Name:      Phone:

Address:

Name:      Phone:

Address:

Questions

Have you ever been a member of another fire / rescue organization? If so, please provide details here.

Do you have any formal fire / rescue training? If so, describe:

Briefly give reasons for wanting to become a member of the LVFC:

Have you ever been convicted of a felony? If so, explain:

Do you have a valid Virginia driver's license? Yes No

Have you ever used illegal drugs? Yes No