This form may be submitted on-line, or printed out and mailed to: GWGVFD, 801 Russell Ave., Gaithersburg, MD 20879. To start the process of becoming a member of the Gaithersburg - Washington Grove Volunteer Fire Department please fill in each space in this form. After we receive your application you will be contacted and invited to attend a prospective-member orientation meeting. At this meeting you will need to provide: A check or money order for $10.00, made payable to GWGVFD Fireman's Fund. This is a non-refundable application fee. A photocopy of your high school diploma or equivalent. A photocopy of your Maryland Motor Vehicle Record, which is obtainable from any MVA office. Before you go fill out this application be sure that you have read the minimum requirements for, and obligations of, GWGVFD membership that are listed on our Volunteer With Us page.

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Personal Information
Name:
Address:
City and State:
Zipcode:
Home Phone:
Cell Phone:
Work Phone:
E-mail address:
Are you 18 years or older?:		Yes No
Emergency Contact Information
Name of Contact:
Address of Contact:
City and State of Contact:
Zipcode of Contact:
Home Phone of Contact:
Cell Phone of Contact:
Work Phone of Contact:
Employment Information
Current Employer
Current Employer Name:
Address of current employer:
City and State of current employer:
Phone of current employer:
Dates of Employment:
Position at current employer:
Former Employer
Former Employer Name:
Address of former employer:
City and State of former employer:
Phone of former employer:
Dates of Employment with former employer:
Position with former employer:
Background Information
Drivers License Number:
Drivers License State:
Drivers License Expiration Date:
Has your drivers license ever been suspended or revoked?:		Yes No
If "yes" explain the circumstances, including dates::
Have you ever been convicted/sentenced/placed on probation for a criminal offense or serious traffic offense? :		Yes No
If "yes" give details, including charge, location and disposition of case::
Education and Training
High School Name:
Dates Attended:
Field of Study:
Did you graduate?:		Yes No
College Name:
Dates Attended for College:
Field of Study at College:
Did you graduate from College?:		Yes No
Other Education:
Dates Attended (other education):
Field of Study (other education):
Did you graduate (other education)?:		Yes No
List any fire-science or related courses you have taken, (e.g. EMT-B, Basic FF):
Have you ever applied to this Department before?:		Yes No
If so, when?:
Have you ever been a member of the GWGVFD?:
If been a GWGVFD member, when?:
Have you ever served in another Fire Dept?:		Yes No
If served in another Fire Dept., where and when?:
What, if any, is the highest rank you have held in any department?:
List the types, if any, of fire/rescue vehicles you have driven:
List TWO references who are not related to you
Reference One
Name of 1st Reference:
Address of 1st Reference:
City/State for 1st Reference:
Home Phone of 1st Reference:
Cell Phone of 1st Reference:
Work Phone of 1st Reference:
E-mail address of 1st Reference:
Reference Two
Name of 2nd Reference:
Address of 2nd Reference:
City/State for 2nd Reference:
Home Phone of 2nd Reference:
Cell Phone of 2nd Reference:
Work Phone of 2nd Reference:
E-mail address of 2nd Reference:
Type of membership desired:		Active: ride fire/rescue apparatus as Emergency Medical Technicians, Paramedics or Firefighters. Administrative: help with non-operational duties on a regular basis. Associate: help with non-operational duties irregularly. Junior Fire Brigade (JFB): a program designed for teens ages 14 - 17.
Vaccine Status - Immunized against COVID-19?:		Yes No
By submitting this form I authorize the investigation of all statements made herein. I understand that any false statements or omissions of information requested is cause for rejection of my application. Further, I understand that my membership, (if Active), is dependent upon my successful completion of the Montgomery County Volunteer Fire/Rescue physical to be conducted by the Department's choice of physician and at their expense, in accordance with standards established by Montgomery County, and that if I do not pass the physical exam an appeal process is available through the Fire/Rescue Commission.