Kunkletown Volunteer Fire Company Application

MEMBERSHIP APPLICATION

Dues are $15 upon acceptance and $1 a year thereafter
Kunkletown Volunteer Fire Company

Station 28
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To The Members of KUNKLETOWN VOL. FIRE CO.:

Do hereby apply for membership in the Kunkletown Volunteer Fire Department. I can truthfully state that I am a resident of Eldred Township and have been for years. I swear all information herein is true and accurate.
Signature
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MonthDayYear
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PLEASE PRINT AND ANSWER ALL QUESTIONS COMPLETELY AND ACCURATELY.
Name

First NameMiddle InitialLast Name
Address

Address

Street Address Line 2

CityState

Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
D.O.B
Driver's License #
Years at Current Address
Previous address if less than 2 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you 18 years or older & out of high school?
Do you have any previous Firefighting experience?
If yes, please list company and dates.
LIST ANY FIREFIGHTING CERTIFICATES HELD: (Must provide copies of certificates)
Certificate Upload:

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Do you have a current and valid PA driver's license ? IF no, please explain why
IF no, please explain why
Were you ever convicted of a felony or misdemeanor? If yes, please explain
IF yes, please explain why
Have you ever been charged or convicted with arson or any other offenses related to starting fires?
Were you ever a member of KUNKLETOWN VOL. FIRE CO. ? If yes, when and under what name?
If yes, when and under what name?
By initialing here, I agree to submit to any drug and alcohol testing at any time at the request of the fire company , including blood and urine testing, if requested. I understand that my refusal to so agree will result in my application being denied and if I refuse to the same subsequent to being a member, it may result in the immediate termination of my membership.
IN CASE OF EMERGENCY PLEASE NOTIFY:
Name
Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState

Zip Code
Secondary Contact
Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Please list any allergies or other pertinent medical information
Do you have any health defects, heart problems, back injuries/problems? Please list any problems, current status, and attending physician.

Please list three individuals who have knowledge of your personal character, ability, and work ethic. These individuals should not be relatives or short-term acquaintances, and should be available for investigation.

Rows	Name	Address	Telephone	Occupation
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By signing this application the applicant understands that being a member of the Kunkletown Volunteer Fire Company is a privilege not a right. If the applicant is accepted as a member, being so accepted as a member does not create any implied or expressed property right of the applicant to continuing membership in the fire company.

I hereby authorize KUNKLETOWN VOL. FIRE CO. to investigate any and all information submitted on this application, including a Criminal Background Check, and upon my signature below do attest that all information presented is true and correct to the best of my knowledge, information and belief.
Signature of applicant
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Should be Empty:

MEMBERSHIP APPLICATION

Kunkletown Volunteer Fire Company