Application For Membership

 

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You may mail this application to the above listed address or bring it in person to a regular meeting, held every 4th Monday of the month. Applicants under 18 years of age must also submit working papers before allowed to become active - all State and Federal Child Labor Laws apply. You may be contacted for an oral interview after submission of this form. To be voted on as a regular member you must attend two (2) regular meetings within ninety (90) days of membership request. At the 2nd regular meeting you will be voted on by secret ballot. A copy of criminal back ground check form SP-4-164(12-99) must be completed by the state and turned in by the 2nd meeting.

 

Please enter your Last Name, First Name, MI

References: please list two (2) references who have known and/or worked with you for at least five (5) years.

1. Name:   Phone: 
Address: 
2. Name:   Phone: 
Address: 

Applicant Information

Last Name   First Name   Middle Name 

Street Address   Home Phone  -  - 

Mailing Address (if different than street)  City   State  Zip 

Date of Birth  -  -   Height (feet-inches)  -   Weight   Hair Color   Eye Color 

Social Security Number  -  -   Drivers License   Class(s)  -   Expiration  -  - 

Applicant's Employer

Employer   Occupation 

Employer Address 

Will you be permitted to take emergency calls during working hours?  Yes    No 

Physical Information

What is your physical condition?  Good    Fair    Poor 

If fair or poor, explain:

Family Physician   Office Phone  -  -   Address 

Have you ever been admitted or advised to be admitted to a mental institution?  Yes    No 

If yes, explain:

List any fire / rescue organizations you belong(ed) to now or in the past:

List any other organizations you currently belong to:

List any current certifications you have (i.e. First Aid, EMT, EMT/P, Rescue, Fire Fighting, etc.) along with expiration dates (if applicable):

If you have certificates of previous training, please include copies of your certificates with your application.

Select the membership category you are applying for:

 Regular (Probationary) - This category is for the individual who is at least 18 years of age. The applicant may be required to have an oral interview with members of the Fire Company.

 Junior Regular (Probationary) - This category is for the individual who is between the ages of 14-17 years old, and who lives within the Port matilda Fire Company's primary coverage area. All applicants MUST present working papers before becoming active. The applicant may be contacted for an oral interview with members of the Fire Company. (ALL State and Federal child labor laws apply)

 Social / Auxiliary - This category is for the individual who wishes only to support the Port Matilda Volunteer Fire Company either financially or with functions other than fires (or any kind of emergency or natural disaster response), i.e. carnival, dinners, etc. This classification has no eligibility requirements since the individual is not permitted to participate in any firematic functions. The individual will not be allowed to run or to hold any office / position in the Port Matilda Volunteer Fire Company. This classification does not require any interview or mandatory attendance at two (2) meetings within 90 days.

Briefly explain why you want to join the Port Matilda Volunteer Fire Company:

I, the undersigned, certify that the above statements are true and complete to the best of my ability, and any statements found to be false will automatically disqualify my eligibility for membership. I authorize the Port Matilda Volunteer Fire Company to make any and all investigations pertinent to this application, and that any findings will be held strictly confidential. I understand that all services rendered during my career of membership are strictly voluntary in nature, and upon acceptance of membership I agree to abide by all rules, regulations, and lawful orders as set and adopted by the Officers and members of the Company. I also agree to take all training as required by the Company.

Signature__________________________     Date of Application_______________