Equal Opportunity Agency: Laytonsville District Volunteer Fire Department, Inc. (LDVFD) values diversity. We are an equal opportunity agency and we do not and will not discriminate on the basis of race, religion, national origin, sex, age, handicap, marital status, sexual preference, or status as a disabled veteran. Information provided on this application will not be used for any discriminatory purpose. A $5.00 non-refundable, processing fee must accompany application in order for it to be processed. This application is not a guarantee, nor an offer of membership.

Indicates Required Field

Date of Application:		05/01/2025 0636
Last Name:
First Name:
Middle Name:
Nickname:
Gender:		Male Female Other
Address:
City, State, Zip:
Social Security Number:
Date of Birth:
Drivers License # and State:
Drivers License Type & Expiration Date:
Phone Number:
Phone Type:		Home Work Cell
Email Address:
Best time to contact:		Morning Afternoon Evening
How were you referred to LDVFD?:		Station Sign LDVFD Website Open House Recruiter Friend Gazette Ad Radio/TV Other
Type of Membership:		EMS Only EMS & Firefighter Administrative
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Address (include city, state, zip):
Emergency Contact Phone Number:
Have you ever applied to or been a member of LDVFD before?:		Yes No
If 'yes' above, please provide dates:
Have you ever served in another Fire/Rescue Department:		Yes No
If 'yes' above, please provide dates of service, name of department, address, phone number, highest rank held, and any other positions held:
List any Fire/Rescue/EMS Courses you have taken, where/how obtained and dates:
Have you ever been refused membership in, suspended, or discharged from ANY Fire or Rescue Department?:		Yes No
If 'yes', please explain:
Please briefly describe your reasons for becoming a volunteer with LDVFD:
Please describe the hours that you would be available (in general) to respond to emergency calls:
Has your drivers license ever been suspended or revoked?:		Yes No
If your drivers license has been suspended/revoked, explain why and give dates:
Have you ever been convicted of any crime(s) other than minor traffic citation(s)?:		Yes No
If YES, when, where and what was the disposition of the offense?:
Educational Background: For all schools attended, please include the names, location (city/state), major course of study, dates attended, and type of degree received:
Employment History: Going back 5 years and starting with your current employer, please provide the name of your employer, position/title, address, phone number, supervisor's name and title, dates of employment, and reason for leaving (if applicable):
List as character references, three (3) persons who you have known for at least three (3) years, who are not related to you and who are not present or past employers. Please include name, relationship, occupation, address, and phone number:
Reference 1:
Reference 2:
Reference 3:
Certification AND Authorization Form (Signed): Either attach signed form to the application before submitting or bring signed form at the time of interview.		Add files...
Please Click Here to download the Certification and Authorization Form Your application will not be processed until this form has been returned.