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: ___________________________________________________
Application for West Roane County Volunteer Fire Department Associate Member, p. 1
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
Application for West Roane County Volunteer Fire Department Associate Member, p. 2