Please complete the information below and submit. The Membership Chairperson will contact you to make arrangements to set-up an appointment. During that appointment the Chairperson will require you to complete an entire application and to complete the necessary paperwork for a BACKGROUND CHECK, PHYSICAL, AND DRUG SCREEN.

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Date/Time:		04/28/2025 0633
Last Name:
First Name:
Middle Name:
Phone Number:
Email:
Age:
Street Address:
City:
State:
Zip Code:
Certifications:		Firefighter I Firefighter II Fire Officer I Fire Officer II Fire Officer III Fire Service Instructor I Fire Service Instructor II Fire Service Instructor III Hazardous Materials Awareness Hazardous Materials Operations Hazardous Materials Technician Swift Water Awareness Swift Water Operations Swift Water Technician American Heart Association Health Care Provider CPR Emergency Medical Responder Emergency Medical Technician - Basic Emergency Medical Technician - Intermediate Emergency Medical Technician - Paramedic Other
I am seeking:		Volunteer Membership Reserve Program Membership Part-time Employment Full-time Employment Junior Firefighter Membership Auxiliary Membership
For more information, call 985-542-6417. You are also invited to come by the station at 42382 Highway 445 next to Champ Cooper School.