Membership Application

 Must be 18 years or older to submit

 

By submitting this application, I hereby certify that the facts set forth in this application, are true and complete to the best of my knowledge. This organization is hereby authorized to make any investigation of my personal and professional history. I understand that if I am accepted into this organization, falsified statements on this application shall be considered sufficient cause for my resignation and legal actions may be taken against me.
 
Junior Membership:
By submitting this application, I hereby certify I am the Parent/Guardian for the applicant agree with the above statement and allow my son/daughter to join and participate with the Smock Volunteer Fire Department according to the rules set forth by the organization.  I hereby relinquish Smock Volunteer Fire Department from any liability regarding my son/daughter’s performance in school work/activities

 

Your Full Name:
Parent/Guardian Name (If applicant is under 18 years of age):
Your Address:
City:
State:
If other state:
Zip Code:
Telephone (Day):
Telephone (Evening):
Email Address:
Please indicate type of membership:
Are you over 18 years of age:Yes
No
If no, can you provide required paperwork for authorization to work:Yes
No
Have you ever been charged with a criminal offense which constituted a felony or misdemeanor or have you plead guilty, no contest, or been convicted of a felony or misdemeanor?:Yes
No
If yes, please explain:
Have you ever been charged with arson or have pleaded guilty, no contest, or been convicted of arson?:Yes
No
If yes, please explain:
Do you have any physical disabilities which would prevent you from performing specific kinds of work?:Yes
No
If yes, please describe in full:
Have you had a serious illness in the past five years?:Yes
No
If yes, please describe in full:
Have you ever received compensation for injuries?:Yes
No
If yes, please describe in full:
Person to notify in case of emergency, phone number, and relationship to applicant:
Employment:
If employed, list of last 3 employers with current first:
Education:
If College Graduate, please indicate:
Please list schools attended with graduaton years:
Driver’s License Number, Class, State, Expiration:
Currently Valid (No suspensions/revocations):Yes
No
If no, please explain:
List any licenses/certification below with expiration dates:
Military Service:
Branch served (if answer none to previous question, go to next section):
Years served (if active, list start date only):
List 3 References (Excludes former employers and/or relatives):

 

 

 

 

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