Application for Regular Membership

I respectfully apply for membership in the Shelton Volunteer Fire Co. #4 Inc. and hereby promise and agree that if admitted to membership, I will conform to the constitution and bylaws of the company and that I will perform to the best of my abilities, all of the duties that may be required of me.  I will also be personally responsible for all equipment and property issued to me.

Personal Information

 

First Name: A value is required. First Name Required. Last Name: Last Name Required. Middle Initial: Date of Birth Wrong month format / incalid format.Minimum number of characters not met.The entered value is less than the minimum required. / A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.

Address: A value is required. City: A value is required. State: Zip Code: A value is required.Invalid format.Minimum number of characters not met.

Phone Number ( A value is required.Invalid format.Minimum number of characters not met. ) A value is required.Invalid format.Minimum number of characters not met. - A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters. Best time to contact you:

Email:

Contact Preference:

 

Education

High School

Name: Location (City, St ) Years attended:

Did you graduate? If Yes, What Year?

College

Name: Location (City, St ) Years attended:

Did you graduate? If Yes, What Year? Major:

Other

Name: Location (City, St ) Years attended:

Did you graduate? If Yes, What Year? Major:

 

Employment

Current Employer:

Address: City: State: Zip Code:

Supervisor: Job Title:

Duties:

 

Emergency Service Experience

Fire

Department Name: Years of Service

EMS

Department Name: Years of Service

Police

Department Name: Years of Service

 

Have you ever been convicted of a felony or misdemeanor?
Do you have any medical problems which could limit your effectiveness as a firefighter?
Please tell us why you want to become a member of Pine Rock Park Co. 4
A value is required.

I hereby certify that all statements in this application are true and complete to the best of my knowledge, and I understand that any answers or statements the I have submitted found to be false will be grounds for immediate dismissal from the company if this application is accepted.

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