West Reading Fire Company #1

Application for Membership

(Please attach non-refundable $10.00 fee to cover processing and first year's membership if accepted.)

Date:______________________

Name: (Last, First) _________________________________________________________________________

Present Address: (Street, City, State, Zip)______________________________________________________

Phone Number: (______)___________________ Date of Birth: _____________________________

Are you a U.S. Citizen? _______Yes_______No

Have you ever been convicted of a crime? (Not including traffic citations)_______Yes________No

If yes, please give details: ________________________________________________________________

Driver's License Number & State:_____________________________Social Security Number:______________

Emergency Service Associations:

Are you or were you ever a member of another fire company, ambulance association or other volunteer organization? _______Yes_______No

If so, what companies?_________________________________________________________________

Were you ever suspended or had membership revoked from another company?_____Yes_____No

If so, what companies?__________________________________________________________________

Why do you want to become a member of West Reading Fire Company? _______________________________

______________________________________________________________________________________

If your membership is approved, do you plan on being: (Check one)

________ACTIVE (Firefighting, fund raising, training)

________SEMI-ACTIVE (Mainly fund raising)

________INACTIVE (Card-carrying member only)

Education:

High School:________________________________________ Graduated? _____Yes _____No

College/Trade School:_______________________________________ Graduated? _____Yes _____No

Do you have any firefighter training? If so, check all that apply:

_______Essentials Module I _______SCBA _______Firefighter I _______Firefighter II

_______Firefighter III _______Pump Operations _______CPR (Expires:________)

 _______Standard First Aid (Expires:________) _______EMT (Expires:________)

_______EMT-P (Expires:_______) ________Haz-Mat Awareness

Other (please specify): _________________________________________________________________

Employment Information:

Present Employer:___________________________________________________

Employer's Address: ______________________________________________________________________

Phone Number: (_______)___________________________ Your Position:___________________________

References:

List three people not related to you whom we may contact for a reference:

Name:_________________________ Address:________________________ Phone:__________________

Name:_________________________ Address:________________________ Phone:__________________

Name:_________________________ Address:________________________ Phone:__________________

Background Authorization:

I have made application to the West Reading Fire Company #1 for membership. This shall constitute formal authorization for the West Reading Fire Company #1 to obtain any and all information which they may request concerning my background history or any and all other information which they in their discretion may deem appropriate. All statements made in this application are true and correct to the best of my knowledge.

Signed:____________________________________________ Date:_____________________

Referred By:___________________________________________________

DO NOT WRITE BELOW THIS LINE

_________________________________________________________________________________

Remarks of the Investigating Committee:______________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________________

We, the Investigating Committee, have investigated the above applicant and do recommend him/her for membership.

__________________________ _________________________________ ________________________