Membership Update FormPlease complete the form below to apply for membership or terminate membership.Membership Update Membership Update Type * New Member Current MemberDual Membership? * Yes No Primary Company Number (If applicable, enter primary company number in this box) Department * Brandy Station VFD Culpeper VFD Culpeper VRS Little Fork VFR Reva VFR Rapidan VFD Richardsville VFR Salem VFR First Name * Last Name * Last 4 of Social Security * Home Address: Street Address * City * State * Zip Code * Home Phone * Cell Phone * Age * Gender * Male Female Date of Birth * Date Joined * Membership Status * Active Fire / EMS Support Auxiliary Junior AssociateEligible for Workmen's Comp * Yes No TerminateEligible for Line of Duty Act * No Fire Rescue Fire & RescueEligible for VA License Relief * Yes No Name for Tag * Tag Color Option * Can Enter IDLH (yellow) Non-Entry (red) EMS Only (blue) Officer (white) Comments Submitted by: * Email of person submitting form: * reCAPTCHA If you are human, leave this field blank. SUBMITΔ
