Application for West Roane County Volunteer
Fire Department Associate Member

Personal Information

Social Security #: _____ - ____ - ______ Date of Birth (m/d/y): ____ / ____ / ____


Name: _____________________________________________________________________
       (Last, First Middle)


Address: __________________________________________________________________
          (Street, City, State Zip)


Phones: Home:(______) ______ - _______   Work:(______) ______ - _______


       Cell:(______) ______ - _______


E-mail: ____________________________________________


General Information

Employer: _________________________________________________________________


Special Skills: ___________________________________________________________


Physical Limitations:______________________________________________________


Any Felony Convictions: ___________________________________________________

In Case of Emergency, Notify:


___________________________________________________________________________
(Name, Phones)


___________________________________________________________________________
(Address, Relation to you)

I understand that I have to take a drug test after
my probationary period to become an Associate Member
of the West Roane County Volunteer fire Department.



Signature:_______________________________________________


Date (m/d/y): _____/_____/______

Please fill this application and mail it to:

West Roane County Volunteer Fire Department
P.O. Box 417
Rockwood, TN 37854