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2. Agency you would like to apply for:*

   1. Axton Life Saving Crew
   2. Bassett Rescue Squad
   3. Fieldale-Collinsville Rescue Squad
   4. Horsepasture Rescue Squad
   5. Ridgeway District Rescue Squad
   6. Axton Fire Department
   7. Bassett Fire Department

   1. Collinsville Fire Department
   2. Dyers Store Fire Department
   3. Fieldale Fire Department
   4. Horsepasture Fire Department
   5. Patrick-Henry Fire Deparmtent
   6. Ridgeway Fire Department
4. Today's Date*
   Today's Date
6. Name*
7. Email Address*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Fax Number
18. Are you 18+ years old?*

    1. Yes
    2. No, I am between 16 and 18 years old
    3. No, I am younger than 16 years old
20. Highest Education Completed
    -- Select One --High School or GEDCollegeGraduate DegreeDoctoral DegreeOther
22. Related Certifications
24. Past Affiliations

    List any Fire or EMS agencies that you have ever been a member of and reason for leaving those agencies:

26. Criminal History*

    Have you ever been convicted of a crime other than a traffic offense?

    1. Yes
    2. No
27. If yes, please explain
29. Driving history*

    Have you ever been convicted of a traffic offense in the past 7 years?

    1. Yes
    2. No
30. If yes, please explain
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field