Personal References: (Please list names, addresses and telephone numbers of three (3) people who know you.
Please do not list relative or former employers.)
I hereby certify that all information contained in this application is true and accurate.
I understand that any information contained in this application which is found to be untrue or
inaccurate will be grounds for my appointment to be rejected or, if appointed,
withdrawn at any time without notice and that the only recourse that I may peruse is an
appeal to the Board of Directors of Lake Monticello Volunteer Fire Department & Rescue Squad Inc.
I also understand, that my appointment/membership may be revoked at any time by a majority vote
of the Lake Monticello Volunteer Fire Department & Rescue Squad Inc.
Board of Directors and that I will have no other appeal. I further agree to abide by the places and
rules of the Corporation and its divisions. You must accept these terms to submit your application.
I authorize the use of any information in this application to enable the Lake Monticello Volunteer Fire Department & Rescue Squad Inc.
(The Corporation) to verify statements made by me in this application and I authorize past employers, doctors, all references,
and any other person to answer all questions asked by the Corporations concerning my ability, character, reputation and pervious employment records.
I release all people who furnish information about me from any and all liability or damages on account of having furnished such information.
You must authorize the use of these inputs to submit your application.
We the undersigned parents or guardian give permission for our son/daughter to become a member of the
Lake Monticello Volunteer Rescue. We also accept responsibility for any equipment willfully destroyed by him/her.
We further give permission for our son/daughter to ride in any Emergency Vehicle, to participate in emergency medical
courses provided by this organization or other state or locally sponsored emergency services,
and to submit to drug testing at the discretion of Lake Monticello Volunteer Rescue Squad.
A signed hard copy of this release will be required prior to final acceptance into the
Providing Fire and Emergency Rescue Services to Fluvanna County, VA residents since 1975
Copyright © 2017 Lake Monticello Volunteer Fire and Rescue Corporation. All rights reserved.