| Todays Date/Time:
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12/01/2024 1628 |
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| APPLYING FOR (PLEASE CHECK ONLY ONE)
Note: If you applying for Special Duties/Social Member, please skip Sections 3, 4, 5 (Emergency Service Information) |
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| Membership Type:
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Junior Firefighter
Firefighter
Fire Police
EMR
QRS Response Only
Social Member/Special Duties
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| SECTION 1 - APPLICANT INFORMATION |
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| First Name:
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| MI:
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| Last Name:
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| Date of Birth:
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| SSN (For Background Check):
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| Primary Phone:
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| Cell Phone Number (if different):
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Current Address:
House number, Street, State, Zip Code
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Mailing Address (if different from current address):
House number, Street, State, Zip Code
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| Email Address:
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| Height:
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| Weight:
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| Blood Type:
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| WILL YOU TAKE A PHYSICAL AT YOUR OWN EXPENSE?: |
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YES
NO
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| SECTION 2 - DRIVER AND BACKGROUND INFORMATION |
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| Driver's License Number:
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| State Issued:
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| Class:
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| MOVING VIOLATIONS OR CITATIONS IN LAST 3 (THREE) YEARS: |
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YES
NO
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If so, please describe violations/citations:
MOVING VIOLATIONS OR CITATIONS IN LAST 3 (THREE) YEARS
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| HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?: |
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YES
NO
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If so, please describe charge(s):
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?
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| SECTION 3 - FIRE TRAINING INFORMATION |
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Please list all training:
You may also attach any certifications
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| Please attach training certifications if you prefer:
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| SECTION 4 - EMERGENCY MEDICAL TRAINING (IF APPLICABLE) |
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| Medical Training:
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N/A
First Aid
EMT
Paramedic
HP
Other
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| Medical Certification #:
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| Medical Certification Expiration Date:
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| SECTION 5 - EMERGENCY SERVICE AFFILIATIONS |
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| CURRENT member of a fire department?: |
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YES
NO
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| If so, please list other CURRENT departments, Contact OFFICER NAME, & PHONE NUMBER:
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| PREVIOUS member of a fire department?: |
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Yes
No
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| If so, please list other PREVIOUS departments, Contact OFFICER NAME, & PHONE NUMBER:
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| SECTION 6 - EMERGENCY CONTACT INFORMATION |
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| Emergency Contact Name:
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| Emergency Contact Address:
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| Emergency Contact Phone Number:
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| Emergency Contact Relationship:
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| How did you hear about becoming a volunteer?:
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Friend
Family
Advertisement
Facebook
Website
Other:
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| Questions/Comments:
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| SECTION 7 - SIGNATURES |
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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.
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AGREE
DISAGREE
N/A
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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.
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AGREE
DISAGREE
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| Parent or Guardian Signature:
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| Parent or Guardian Signature Date Signed:
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| Parent or Guardian Relationship to Minor:
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| Applicant Signature:
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| Applicant Signature Date Signed:
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