Membership Application

THE CITIZEN'S FIRE COMPANY IS A NON-PROFIT ORGANIZATION CHARTERED TO PROTECT LIVES AND PROPERTY. THE DEPARTMENT HAS SEVERAL BRANCHES TO ITS ORGANIZATION. THEY CONSIST OF FIRE CREW, FIRE POLICE, ADMINISTRATIVE AND COMMITTEES. SEVERAL FUNCTIONS THAT THE DEPARTMENT OFFERS ARE FIRE PROTECTION, EMS SERVICE, PUBLIC & COMMUNITY SERVICES, FIRE PREVENTION & TRAINING PROGRAMS TO THE PUBLIC & INDUSTRIES. WE ARE A VOLUNTEER ORGANIZATION AND WE WELCOME ANY INDIVIDUAL WISHING TO COMMIT THEIR TIME WITHOUT PAY TO PROTECT THE WELFARE OF OUR COMMUNITIES.

Date of Application:_____________________________Sponsoring Member:_______________________________

PERSONAL INFORMATION

Name:_________________________________________________
Street:__________________________________ Apt:___________
City:______________________ State:________________ Zip:_________
Home Phone #:________________________Work Phone #:________________________
Social Security #:________-________-________
Driver's Lic. #:_____________________ Class:______________ Exp:___________
Sex (M) or (F) Race:____________ Marital Status (Y) or (N) DOB:_______________
Dependant(s) Name(s) and Birth Date(s): __________________________________________________ __________________________________________________ __________________________________________________

Emergency Contact:_______________________________ Phone:________________ Primary Beneficiary:_______________________________ Relationship:__________________ Second Beneficiary:_______________________________ Relationship:__________________

MEDICAL HISTORY:

Allergies:___________________________________________________________ Prescribed Medication:________________________________________________________

Have you ever filed an application for membership with us before? (Y) or (N) If yes, when?_________________________ Do you have a criminal record? (Y) or (N) If yes,explain:_____________________________________________________ What are your intentions as a member in this Company? (Fire fighter) (Fire Police) (Administrative) Do you possess any special skills or training that will help you perform your duties?_____________________________________________________________________________ Do you have any previous fire department experience? (Y) or (N) If yes, Please list department Name and Contact Information. Person:__________________________________ Phone #:________________________ Person:__________________________________ Phone #:________________________ Person:__________________________________ Phone #:________________________ Do you have any impairments or physical, mental or medical disabilities which would interfere with your ability to perform this job? (Y) or (N) If yes please list:________________________________________________________ (any information or disabilities will not have any influence on acceptance into membership)

APPLICANT'S STATEMENT

I CERTIFY THAT ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION AND CONSENT TO A STATE POLICE BACKGROUND CHECK. IN THE EVENT OF MEMBERSHIP, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION GIVEN IN MY APPLICATION OR INTERVIEW MAY RESULT IN DENIAL OF MEMBERSHIP. I UNDERSTAND, ALSO THAT I AM REQUIRED TO ABIDE BY THE CONSTITUTION AND BY-LAWS GOVERNING THIS COMPANY.

Signature:________________________________________________ Date:___________________ Parental Signature If Under 18 Years Of Age:________________________________________________ Date:__________________

CITIZEN'S FIRE COMPANY DOES NOT CONDONE THE USE OF RECREATIONAL DRUGS. MEMBERSHIP WILL BE TERMINATED IMMEDIATELY IF YOU ARE FOUND USING THEM.

YOUR APPLICATION, ONCE RECEIVED, IS PRESENTED AT THE NEXT COMPANY MEETING. A MEMBER FROM THE COMPANY WILL THEN CONTACT YOU FOR AN INTERVIEW AND THEN AT THE NEXT REGULAR COMPANY MEETING WILL PRESENT YOUR APPLICATION FOR MEMBERSHIP. IF APPROVED, YOU WILL BE PLACED ON A 6 MONTHS PROBATIONARY STATUS. THE CITIZEN'S FIRE COMPANY DOES NOT DISCRIMINATE AGAINST ANY SEX, CREED, COLOR, RELIGION, NATIONAL ORIGIN OR PHYSICAL HANDICAPS. IF ANY PERTINENT INFORMATION CHANGES, YOU ARE RESPONSIBLE TO NOTIFY THE CORRECT PERSON OF THE CHANGE.

FOR FIRE COMPANY USE ONLY:

Date application received:________________ Interview held on:_____________________ By:_________________________ State Police check ordered:___________________________ Received:____________________________ Approved for probationary membership:__________________________ Received copy of Constitution and By-Laws:____________________________ Completed Workman's Comp. Information:____________________________