Volunteer

Join BVFD

No experience required — full training provided at no cost. Complete the official Louisa County volunteer application below.

VOLUNTEER SERVICE APPLICATION

County of Louisa — Department of Fire and EMS

Dear Applicant: You must complete all sections of this application. Volunteer service with any Louisa County station, agency, department, company, or organization is at-will and may be terminated at any time with or without notice and with or without cause. This application involves volunteer service only and does not create or confer any employment rights on the volunteer. The County of Louisa expressly disclaims any employment obligations whatsoever for volunteers accepted into service.

Station You Wish to Volunteer

Personal Information

Full Name *

Street Address *

City / State

Zip Code

Phone *

Date of Birth (mm/dd/yyyy) *

Email Address *

Have you ever been a member of, or applied for volunteer membership to, any station, agency, organization, company, or department of Louisa County?

YesNo

Emergency Contact Information

Name

Relation

Address

Day Phone

City / State

Evening Phone

Phone

Criminal History

Have you ever been convicted of any crime? Include misdemeanors, traffic offenses, and/or felonies. Affirmative answers do not necessarily disqualify the applicant from consideration.

YesNo

Do you consent to a search of conviction information from your local, state, and national criminal history files?

YesNo

Medical History

Do you have any medical conditions or physical limitations that should be considered?

YesNo

Are you currently receiving any special medical treatment or medications?

YesNo

Qualifications, Skills & Training

List any fire, rescue, EMS, and/or emergency management training, experience, and certifications you currently hold. Include expiration dates and certifying state, department, or agency.

Certification	Certifying State / Department / Agency	Expiration Date

List any special qualifications, skills, certificates, and/or licenses you hold. Include armed forces training, machine skills, professional memberships, trade school backgrounds, etc.

Driving Record

Do you have a valid driver's license?

YesNo

Do you consent to the release and review of your Driver's Transcript or Record now and on a periodic basis during service for repeated or significant traffic violations?

YesNo

References — List three (3) references known for at least 2 years. Do not include relatives.

Reference 1

Name

Relation

Address

Phone #

City / State

Time Known

Reference 2

Name

Relation

Address

Phone #

City / State

Time Known

Reference 3

Name

Relation

Address

Phone #

City / State

Time Known

How Did You Hear About Us?

Certification & Agreement — This statement must be signed

I hereby certify that the facts set forth in the above Volunteer Service Application are true and complete to the best of my knowledge, and I have not intentionally omitted any information. I further certify that there are no willful misrepresentations or falsifications of the above statements and answers to questions. If an investigation discloses such misrepresentations, omissions, and/or falsifications, my application could be rejected, and I could be disqualified from ever providing volunteer service with the Louisa County Department of Fire and EMS agencies in the future. Louisa County Department of Fire and EMS and/or any representative thereof is hereby authorized to make investigation of my personal history, criminal history and driving record. I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies duly accredited. I understand that nothing said or implied during the application process should be deemed to constitute the terms of a contract. Volunteer service with any Louisa County station, agency, department, company, or organization is at will and may be terminated at any time, with or without notice, and with or without cause.

I understand and agree that, if I am accepted as a volunteer, I am not considered an employee of the County of Louisa for any purpose, and I am entitled to no employment rights or benefits whatsoever from the County of Louisa. Rather, this application involves volunteer service only, and creates no employment rights or obligations.

Signature of Applicant *

Sign above using mouse or touch

Signature required

Date

Printed Name of Applicant *

Volunteer Inquiry Release — Background Check Authorization

In conjunction with my volunteer application, I understand that Louisa County intends to obtain Consumer Reports and/or Investigative Consumer Reports about me as defined in the Fair Credit Reporting Act (FCRA). These Reports may include information concerning my character, academic background, credentials, work habits, work performance, work experience, employment history, motor vehicle record, education background, civil litigation history and/or criminal record. I have read the above disclosure and I hereby authorize Louisa County, Selection.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. This authorization shall remain on file and shall serve as an ongoing authorization. A photocopy or facsimile of this authorization shall be as valid as the original.

The following information is required to conduct the background investigation

Last Name *

First Name *

Middle Initial

Suffix (Jr., Sr., etc.)

Social Security Number *

Previous / Maiden Name

Phone Number

Email Address

Street Address

City

State

Zip

Driver's License Number

State Issued

Date of Birth (for identification purposes only)

Age is a protected characteristic and will not be used as the basis for any decision.

List states and counties of residence, other than above, for the past 7 years:

County 1

State

County 2

State

County 3

State

Notice to Applicants in CA, OK, or MN: By checking this box, I request to receive a free copy of any Report ordered on me.

Signature — Volunteer Inquiry Release *

Sign above using mouse or touch

Signature required

Date

Louisa County — Volunteer Acknowledgement of Driving Record Requirements

Volunteer Name *

Date

I acknowledge that as a condition of my use of a County vehicle that I must submit a copy of my driving record each year. I further acknowledge that if my driving record changes in any way that I must notify the County within five business days. I understand that to withhold this information constitutes a violation of the use of the County vehicle policies.

Volunteer Signature — Driving Record Acknowledgement *

Sign above using mouse or touch

Signature required

As the County can have the DMV report processed, I give my permission to the County to run a DMV report annually and more often if required. To accomplish this, I must supply the County with the following information:

Full Name

Date of Birth

Driver's License Number

I hereby grant Louisa County permission to obtain a copy of my driving record by signing:

Volunteer Signature — DMV Permission *

Sign above using mouse or touch

Signature required

Your application will be reviewed by the BVFD membership committee and forwarded to Louisa County Fire & EMS. Information is kept confidential.