| Todays Date/Time:
|
 |
05/02/2024 1743 |
|
| APPLYING FOR (PLEASE CHECK ONLY ONE)
Note: If you applying for Special Duties/Social Member, please skip Sections 3, 4, 5 (Emergency Service Information) |
|
| Membership Type:
|
|
Junior Firefighter
Firefighter
Fire Police
EMR
QRS Response Only
Social Member/Special Duties
|
|
| SECTION 1 - APPLICANT INFORMATION |
|
| First Name:
|
|
|
| MI:
|
|
|
| Last Name:
|
|
|
| Date of Birth:
|
|
|
| SSN (For Background Check):
|
|
|
| Primary Phone:
|
|
|
| Cell Phone Number (if different):
|
|
|
Current Address:
House number, Street, State, Zip Code
|
|
|
Mailing Address (if different from current address):
House number, Street, State, Zip Code
|
|
|
| Email Address:
|
|
|
| Height:
|
|
|
| Weight:
|
|
|
| Blood Type:
|
|
|
| WILL YOU TAKE A PHYSICAL AT YOUR OWN EXPENSE?: |
|
YES
NO
|
|
| SECTION 2 - DRIVER AND BACKGROUND INFORMATION |
|
| Driver's License Number:
|
|
|
| State Issued:
|
|
|
| Class:
|
|
|
| MOVING VIOLATIONS OR CITATIONS IN LAST 3 (THREE) YEARS: |
|
YES
NO
|
If so, please describe violations/citations:
MOVING VIOLATIONS OR CITATIONS IN LAST 3 (THREE) YEARS
|
|
|
| HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?: |
|
YES
NO
|
If so, please describe charge(s):
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?
|
|
|
|
| SECTION 3 - FIRE TRAINING INFORMATION |
|
Please list all training:
You may also attach any certifications
|
|
|
| Please attach training certifications if you prefer:
|
|
|
|
| SECTION 4 - EMERGENCY MEDICAL TRAINING (IF APPLICABLE) |
|
| Medical Training:
|
|
N/A
First Aid
EMT
Paramedic
HP
Other
|
| Medical Certification #:
|
|
|
| Medical Certification Expiration Date:
|
|
|
|
| SECTION 5 - EMERGENCY SERVICE AFFILIATIONS |
|
| CURRENT member of a fire department?: |
|
YES
NO
|
| If so, please list other CURRENT departments, Contact OFFICER NAME, & PHONE NUMBER:
|
|
|
| PREVIOUS member of a fire department?: |
|
Yes
No
|
| If so, please list other PREVIOUS departments, Contact OFFICER NAME, & PHONE NUMBER:
|
|
|
|
| SECTION 6 - EMERGENCY CONTACT INFORMATION |
|
| Emergency Contact Name:
|
|
|
| Emergency Contact Address:
|
|
|
| Emergency Contact Phone Number:
|
|
|
| Emergency Contact Relationship:
|
|
|
| How did you hear about becoming a volunteer?:
|
|
Friend
Family
Advertisement
Facebook
Website
Other:
|
| Questions/Comments:
|
|
|
|
| SECTION 7 - SIGNATURES |
|
MINOR INFORMATION - PLEASE NOTE!!:
IF YOU ARE UNDER THE AGE OF 18, YOU WILL NEED WORKING PAPERS (WORK PERMIT) FROM YOUR SCHOOL. YOU ,USTALSO OBTAIN A SIGNATURE FROM A PARENT AND/OR LEGAL GUARDIAN GIVING YOU PERMISSION TO JOIN THE ORGANIZATION.
|
|
AGREE
DISAGREE
N/A
|
SIGNATURE AGREEMENT:
I hereby am applying for membership to with the Gallitzin Fire Company No. 1. My membership will become effective upon decision by the Board of Trustees. I also understand that it may be required of me to submit a background check at my expense from the Pennsylvania State Police. When accepted to the organization, I understand that I will remain a Probationary Member of Gallitzin Fire Company No. 1 until at which time I meet any and all standards set forth by the fire company. Furthermore, I understand that I can withdrawal from this company at anytime I so desire and that it must be in writing. I also state that I am of good moral character and I will abide by all polices and procedures set forth by the By-Laws and Standard Operating Procedures for which section of the company I am applying for. I also state that all signatures are my own and not forged, and that all statements are true and forth coming. I understand that any false information of this application will deny me from becoming a member of Gallitzin Fire Company No. 1.
|
|
AGREE
DISAGREE
|
| Parent or Guardian Signature:
|
|
|
| Parent or Guardian Signature Date Signed:
|
|
|
| Parent or Guardian Relationship to Minor:
|
|
|
| Applicant Signature:
|
|
|
| Applicant Signature Date Signed:
|
|
|
