Membership Application

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Use the form below to apply for membership to the Butler Township Volunteer Fire District. After completing this form, a representative of the membership committee will contact you. In the meantime, feel free to browse our website or visit our station to see what the Butler Township Volunteer Fire District is about.

Indicates Required Field

First Name:
MI:
Last Name:
Address:
Email Address:
Primary Phone:
Social Security #:
Date of Birth:
Area(s) of interest:		Full Member (Firefighting/Rescue) Social Stipend Program
Training and Certifications
Training:		Essentials of Firefighting (All 4 modules) Emergency Vehicle Operator Pumps Operations 1 Basic Vehicle Rescue Hazmat Operations ICS 100 ICS 200 ICS 700 ICS 800
Certifications:		Firefighter 1 Firefighter 2 Fire Officer 1 Fire Officer 2 Driver/Operator - Pump Driver/Operator - Aerial HAZMAT Rope Rescue Structural Collapse Confined Space Trench Rescue
Medical Certification:		CPR EMR EMT AEMT Paramedic
Background Information
Previously a member of a fire department?:		Yes No
If yes, which one?:
Have you ever been convicted of a crime, other than a summary traffic violation?:		Yes No
If yes, please explain:
Has your driver's license ever been suspended?:		Yes No
If yes, when and why?:
Administrative Data
Briefly state why you wish to join, what you expect of the department and what you expect to gain from membership.:
In case of emergency notify: (Name, Phone Number, Relationship)
Three References, not related: (Name and Phone Number)
How did you hear about becoming a volunteer?:
Questions/Comments:
Please email copies of all certifications and/or training documentation to membership@btvfd3.com