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
By submitting this application, you agree that all of the above information is true and accurate.