County Volunteer/Career Member Benefits Form
Complete this form for all new Fire & Rescue members to be submitted for purposes of Life Insurance, Clerk of Court, Commissioner of Revenue, and the County Administrator or if you need to remove a member that has left your department.
Status
Please select
Add to
Delete from
Please select
Select Department(s)
Lovingston Fire Department
Piney River Fire Department
Faber Fire Department
Gladstone Fire & Rescue Department
Rockfish Fire & Rescue
Wintergreen Fire Department
Montebello Fire Department
Roseland Rescue Squad
Wintergreen Rescue Squad
Member's First / Last name
Member's Address
Member's Cell Phone Number
Member's Birthdate
MM
/
DD
/
YYYY
Member's County
Please select
Albemarle
Amherst
Appomattox
Augusta
Buckingham
Campbell
Fluvanna
Louisa
Nelson
Rockingham
Spotsylvania
Please select
Member's Home Phone Number
Member Type
Please select
Volunteer
Full-Time Career
Part-Time Career
Please select
Member's Drivers License Number
First / Last name of person completing this form
Email address of person completing this form
Mike's Email address
Haley's Email address
Phone number of person completing this form
Verification
SUBMIT FORM
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