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Membership Application
*All information and references given on the application may be verified by the Fire Company
Applicant Name
Address
Home Phone
Cell Phone
Email Address
Date of Birth
(Working papers will be required if under the age of 18)
Driver's License State & Number
Driver's License Class & Expiration Date
Current Employer or School
Fire Company Sponsor's Name
Reference 1 Name
Reference 1 Phone
Reference 2 Name
Reference 2 Phone
Education Background
High School
College / Vocational School
Post Graduate
Military Experience
Previous Firefighting / Emergency Service Organization Experience
Fire Company / ESO Name
Date(s) of Service
Rank
Fire Chief / Administrator Name
Fire Chief / Administrator Phone
Fire Company / ESO Name
Date(s) of Service
Rank
Fire Chief / Administrator Name
Fire Chief / Administrator Phone
Total Years of Service
Fire Schools / Training (Firefighter, Rescue, EMS, etc)
2.
3.
4.
5.
Health Information
Is there any reason that your present health condition would restrict your activities as a firefighter / emergency service provider? (If yes, please explain)
Do you suffer from any fear / phobias that would restrict your activites as a firefighter / emergency service provider? (Fear of height, claustrophobia, etc.)
Emergency Contact Person
Emergency Contact Phone Number
Emergency Contact Cell Number
Beneficiary
Relationship
Background Information
Have you every been convicted of a crime? (If yes, please explain)
All Applications are to be submitted with
1. $1.00 Yearly Dues
2.
PA State Police Background Check
3.
PA Child Abuse History Clearance
By submitting this application, you agree that all of the above information is true and accurate.