This form may be submitted to start the process of becoming a Junior Fire Brigade (JFB) member of the Gaithersburg - Washington Grove Volunteer Fire Department (GWGVFD).  Please fill in each space in this form.  After we receive your application, you will be contacted by the JFB coordinator to attend a JFB interview.  A parent or guardian must be present at this interview as well.

At this interview you will need to provide:  A photocopy of your current high school transcript.  A photocopy of your Maryland Motor Vehicle License (if applicable).  Before you fill out this application be sure that you have read the minimum requirements for, and obligations of, GWGVFD JFB membership.  Please note applicants must be enrolled in an accredited high school program or equivalent and must be at least 14 years of age. Questions can be directed to: JFBCoordinator@gwgvfd.org

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Personal Information
Name:
Address:
City and State:
Zip Code:
Home Phone:
Cell Phone:
E-mail address:
Are you 18 years or older?:		Yes No
Education and Training
High School Name:
Dates Started:
Did you graduate?:		Yes No
List any fire-science or related courses you have taken, (e.g. CPR, First Aid Training):
Have you ever applied to this Department before?:		Yes No
If so, when?:
Have you ever served in another Fire Dept?:		Yes No
If served in another Fire Dept., where and when?:
Emergency Contact Information
Name of Contact:
Address of Contact:
City and State of Contact:
Zip Code of Contact:
Home Phone of Contact:
Cell Phone of Contact:
Work Phone of Contact:
Email of Contact:
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 arrested/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:
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:
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.