Membership Application Form
Personal Information
What type of membership do you wish to be considered for?
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Active
auxiliary
Social
Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Home/Work Phone
*
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Area Code
Phone Number
Email
*
example@example.com
Date of birth
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Month
-
Day
Year
Date
Residence Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Employer:
Are you legally entitled to work in the United States?
*
Are you 18 years of age or older?
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Do you have a current NYS Driver’s License?
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What is your drivers license number:
Are you willing to participate in a annual medical check required of potential volunteer firefighters?
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Have you ever attended any firematic training
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If so please list the class and date
Skills and Experience
Please indicate if you have any of the following skills or training
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CPR - Cardiopulmonary resuscitation
EMT-B / Emt-A / Paramedic
First Aid
PAD/Defibrillation Training
Certified Trade - mechanic, electrician
Fire Safety Systems - alarms, extinguishers
Rescue procedure - lifeguard, auto extrication
Knowledge of breathing apparatus - scuba diving, etc
Other
Please list any previous Volunteer Firefighter Experience:
Date: Department
Other volunteer experience:
Date: Organization
References
Please supply 3 references that are not family
Additional Comments
Date
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-
Month
-
Day
Year
Date
I understand that this is just a preliminary application and in no way constitutes a offer for membership to Palenville fire Department or any of it's associate groups.
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Submit
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