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Volunteer Application

First Name *
Middle Name *
Last Name *
Address *
City *
State *
ZIP *
Email *
Phone (XXX-XXX-XXXX) *
Date of Birth (MM/DD/YY) *
Gender *
Do you have a valid Virginia driver's license? *
Volunteer Preference *
Which department are you interested in joining?
Highest education obtained?
Have you been affiliated with any other fire and rescue organizations within the past 3 years? *
If so please list agencies and dates:
Have you ever been convicted of a felony? *
Have you ever been the subject of a complaint regarding neglect of an animal, child, the elderly, or anyone in your care? *
Do you have any traffic violations within the past 3 years? *
If you answered yes to any of the above, please provide the offense and date
Reference Name #1
Relationship 1
Phone Number 1
Reference Name #2
Relationship 2
Phone Number 2
Reference Name #3
Relationship 3
Phone Number 3
How did you hear about us?
If other please describe:
If refered by an individual, please provide individuals name

Affirmation

A criminal background check and DMV report is required for all volunteers. You will be contacted in person to give your social security number. By pressing the above submit button, I certify that I have completed this application to the best of my knowledge and ability. I certify that the above information is true, complete and accurate. Falsification of information is grounds for dismissal. I also understand that I am giving permission to Botetourt County to run a criminal background check and DMV report.

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