Holland Township Volunteer Fire Co.
971 Milford-Warren Glen Road
Milford, NJ 08848
Name: (Last, First, MI)
Mailing Address:
City: State: Zip:
Street Address
City: State: Zip:
Birthplace Date: Blood Type:
Present Residence in For Years
Social Security # - - Home Phone
Have you ever been convicted of any criminal offense? Yes, No
If so, when and where
Experience Driving heavy duty trucks? Yes, No
Drivers License # Eye Color
(Note: all driver’s licenses will be checked by local police_
Have you ever been a firefighter? Yes, No.
If so, when Where
Employer Business Phone
Occupation Shift Worked
Proposed By
____________________________________
Signature of Applicate Date
In case of emergency, person to notify Phone __________________________
______________________________
Signature of Chief Date Committee Approval Date