Application for Membership

Mount Gretna Fire Company

Application For Membership

 

Membership Desired         Regular__  Junior__  Contributing__  Fire Police__

 

Last Name__________________First Name_______________Middle Name__________

Address_________________________________________________________________

____________________________________________How Long?   Yrs___Mos._______

Previous Address If At Current <1 Yr_________________________________________

Home Phone(       )_________________Cell Phone(       )__________________________

D.O.B.______-_____-__________SSN_______-_____-____________

Drivers License #_______________________State______Class____________________

Email Address                                                                   __________________________

Please Attach A Copy Of License, Photo ID etc.

 

Employment History

 

 

Current Employer_________________________________How Long?_Yrs.___Mos.___

Address_____________________________________Phone(       )__________________

Job Title / Description______________________________________________________

 

 

Previous Employer________________________________How Long?_Yrs.___Mos.___

Address_____________________________________Phone(       )__________________

Job Title / Description______________________________________________________

Reason For Leaving_______________________________________________________

 

References

(List only references who have definite knowledge of your qualifications for the position of application. Do not list relatives, former employers, persons living outside the U.S.)

 

Name________________________Phone #______Yrs. Known_____Best Time To Call

 

1______________________________________________________________________

2______________________________________________________________________

3______________________________________________________________________

 

 

Firefighting / Emergency Services Experience

(Include date, organizations names, addresses and phone numbers. Attach copies of certificates.)

 

 

 

 

 

Medical Conditions

Do you currently have any medical conditions that would prevent you from performing any firefighting duties?      YES_____  NO_____    If yes please explain

-_______________________________________________________________________

-_______________________________________________________________________

-_______________________________________________________________________

 

Criminal Background

Have you ever been arrested for a crime (including traffic violations) and / or do you have any criminal charges against you  YES_____  NO_____  If yes, please explain

-_______________________________________________________________________

-_______________________________________________________________________

-_______________________________________________________________________

 

 

Date Application Received______________________________

Findings of the investigation committee,

FAVORABLE_____  UNFAVORABLE_____

Signature of investigating Committee_____________________________

DaTE OF VOTE FOR PROBATIONARY MEMBERSHIP_____________YES__no__

dATE OF VOTE FOR ACTIVE MEMBERSHIP_____________________yES__no__

 

Emergency Contact Info

In Case Of An Emergency Notify_____________________________________________

Phone # 1     (       )_______-__________

Phone # 2     (____)______-__________

Relationship Of Emergency Contact__________________________________________

 

Beneficiary Information

 

Primary Beneficiary________________________________Relationship_____________

Address_________________________________________________________________

City_________________________________State__________Zip__________________

Phone (_____)______-________        SSN________-_______-__________

Secondary Beneficiary_____________________________Relationship______________

 

Member Signature________________________________Date_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To Be Completed By Parent/Guardian of Minors

For applicants under 18 years of age, parental or guardian consent is required. Also there is a state law (P.L. 286 No. 177) requiring applicant to have working papers. Please attach copy of papers to application.

 

I___________________the parent or guardian of________________________do hereby consent to him or her becoming a member of the Mount Gretna Volunteer Fire Company

 

Signed_________________________________________________

 

 

Date___________________________________________________

 

 

 

 

Please read and sign below

 

As an applicant of the MOUNT GRETNA FIRE COMPANY, I do hereby agree to abide by all organization By-Laws set forth. Furthermore, I do understand that I must follow directions from instructors and all company officers. I also agree to permit the MOUNT GRETNA FIRE COMPANIY to make all necessary inquiries and investigations relating to validity of these statements which I have made on this application. I shall at all times endeavor to the best of my ability to serve, protect, and better the organization of the MOUNT GRETNA FIRE COMPANY.

 

I also understand that misrepresentation of the facts may be cause for dismissal or rejection of this application.

 

Applicant Signature___________________________________Date_________________

 

 

 

 

 

 

 

 

 

 

 

MOUNT GRETNA FIRE COMPANY

 

Authorization for Background Check

 

I, (print name)____________________________      , do hereby authorize the membership

committee of the Mount Gretna Fire Company, Lebanon County to conduct a criminal and/or driving background check on me. I understand that the results, if deemed necessary by said committee, will be presented to the full membership of said fire companies for the purpose of voting on my application, for membership into said fire company. I also understand that if I do not give my permission to have these checks done that it may hinder my acceptance into the said fire company.

 

Social Security Number_________________________________________________

 

Applicant Signature____________________________________________________

 

Witness_____________________________________________________________

 

Date____________________________