Your Full Name (First, Middle, Last, Suffix):

Your Address:

City:

State:

Zip Code:

Telephone (Current Home):

Telephone (Current Cell Phone):

Email Address:

Age

Birthday (MM/DD/YYYY)

Social Security Number:

Driver's License Number:

Driver's License State:

Driver's License Expiration Date:

High School Attended (Please indicate highest grade completed):

College Attended:

Degree / Educational Concentration:

Interest Area (Administration, Communications, Emergency Medical Service [EMS], Explorer Program, Fire, Fire/EMS, Fire Police, Fundraising, Other:

Are you a member of another Fire Company / Department?

Location of the Fire Company / Department?

Chief's Name and Phone Number:

List Any Experience (Bring any/all certifications to interview):

Do you have any health / physical conditions that would interfere with you providing emergency service?

Please describe any health or physical conditions that would interfere with providing emergency services:

Emergency Contact (Please provide Name and Best Method of contact):

I hereby understand it is my responsibility to furnish and provide Background / Criminal History (Please bring copies of any/all clearances and background checks with you to your interview date):

Arrested

Plead Guilty

Convicted

Please include all summaries, misdemeanors, felonies, and traffic history:

List 3 People (including Name, Phone, and Address) not related to you that have known you for more than 3 years:

I authorize the Loyalsock Volunteer Fire Company to perform any additional criminal background check on my behalf and understand it is my responsibility to complete such forms to include the same information regarding my past criminal history as a requirement for membership. In addition, I authorize Loyalsock Volunteer Fire Company to contact my list of references provided as part of my character makeup prior to and following membership interview..

I understand that if I'm accepted as a regular or a live-in member of the Loyalsock Volunteer Fire Company that I must abide by the rules, regulations, and guidelines set forth in the trustee manual, bylaws, Company Constitution, and the Live-In guidelines.

I hereby acknowledge and understand there is a $10.00 non refundable administration/application fee due prior to or at the time of membership interview. Administration/Application fee can be made payable by check (Loyalsock Volunteer Fire Company) and mailed with attention to Membership Committee, Loyalsock Volunteer Fire Company, 715 Northway Road, Williamsport PA 17701 with applicant name in the For or Subject area of the check.

I understand that during the membership interview, additional questions, forms, and documenation may be required to complete my membership application.

I hereby acknowledge all information filled out in the above sections to be correct and fully accurate. Any failed or false information will be documented and open to disclosure during interview process. If you accept the terms and conditions, please digitally type in your full name and click submit below.

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