2. Note
   The Wingate Volunteer Fire Department Inc. would like to thank you for filling out an interest form for membership. We ask that you fill out the requested information below in order for us to line up an oral interview and obtain additional information. You must be 18 years old with a high school diploma or GED for membership and a valid driver's license. For Junior Membership, you must be 16 years old, have a valid driver's license and currently enrolled in school.
4. Date
   Date
5. Check One That Applies

   1. Member
   2. Junior Member
7. Name
8. Email Address
10. Address
12. City
13. State
14. Zip Code
16. Home Phone Number
17. Cell Phone Number
21. 3 References
23. Reference 1 Name
24. Years Acquainted
26. Address
28. City
29. State
30. Zip Code
32. Phone Number
34. Reference 2 Name
35. Years Acquainted
37. Address
39. City
40. State
41. Zip Code
43. Phone Number
45. Reference 3 Name
46. Years Acquainted
48. Address
50. City
51. State
52. Zip Code
54. Phone Number
58. Have you ever been with a fire / rescue department?

    1. Yes
    2. No
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field