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

Submit