GWGVFD Application Form

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.

Personal Information		Emergency Contact Information
Name Address City and State Zipcode Home Phone Work Phone E-mail address OR Check if no email address is available. Are you 18 years or older? Yes No		Name Address City and State Zipcode Home Phone Work Phone
Employment Information
Current Employer		Former Employer
Name: Address City and State Phone Dates of Employment Position		Name Address City and State Phone Dates of Employment Position

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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
Field of Study
Did you graduate?:	Yes No
Other Education:
Dates Attended:
Field of Study:
Did you graduate?:	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?:	Yes No
If so, when?:
Have you ever served in another Fire Dept?:	Yes No
If so, 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:
Address:
City/State:
Home Phone:
Work Phone:
Email Address:	OR Check if no email address available.
Reference Two
Name:
Address:
City/State:
Home Phone:
Work Phone:
Email Address:	OR Check if no email address available.
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.

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.