Membership Application

Personal Information:

Name*

Email*

Street Address*

Unit#/Apt#

City*

State*

Zip*

Date of Birth*

Age*

Driver’s License Number*

Home Phone*

Cell Phone*

Prior Experience:

Do you have any prior firefighting experience?*

Yes

If so where?

Chief’s Name

Phone Number

E-mail

Current Employment:

Name of Employer

How Long?

Full Address

Phone

Work Hours

Why do you want to join the fire company?*

Type of Membership:

Select membership class desired:*

Class A – I understand I will have to obtain Fire Fighter 1 certification to become active

Class B – I will serve on committees and help with fundraising events

Acknowledgement

By submitting this application, I certify that the information contained herein is both true and accurate. I understand that I will be on probation for 6 months. I further understand the I must submit the following items (We recommend you complete these first):
1. A Pennsylvania Criminal Record Check – This can be obtained by visiting: https://epatch.pa.gov/home and selecting Volunteer Record Check.
2. A Pennsylvania Child Abuse Certification – This can be obtained by visiting: https://www.compass.dhs.pa.gov/cwis and creating an individual account. You will submit a Volunteer Record Check.

3. A copy of your valid driver’s license.
If you obtain any of these for your employer, you may submit copies of those to us. Use the boxes below to upload these documents. Note: a copy of your driver’s license must be uploaded with this application.

Upload your Driver’s License here (This is required)*

Drivers License

Upload your Criminal Background Check here

Criminal Background Check

Upload your Child Abuse Clearance here

Child Abuse Clearnace