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Verification Form for Participation in Mississippi Volunteer Firefighter ... 2026

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The document is a verification form for the Mississippi Volunteer Fire Fighter Telemedicine Program, certifying that an applicant is an active volunteer firefighter. It includes sections for the County Fire Coordinator and the applicant to provide their information and signatures, confirming the applicant's eligibility for the program.

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In Section 1, the County Fire Coordinator should complete the certification. Enter the printed name of the applicant, followed by their address, city, state, and zip code.
The Volunteer Fire Chief must sign and print their name, along with the name of their department to confirm the applicant's active service.
Next, as the County Fire Coordinator, provide your signature and printed name to certify that the applicant is actively serving.
In Section 2, the applicant should fill in their date and telephone number. They must then sign and print their name to affirm that all statements are true.

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