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____________________________