Utah State Firefighters' Association
Organized September 16, 1908 Incorporated August 17, 1910
Application for Membership
Send your payment of $25.00 ($10.00 activation and $15.00 Yearly Dues) to USFA c/o Sam Larson, 1609 Shivwits Drive, St. George, UT 84790. After the initial payment, you will be invoiced for $15.00 per year, and you will receive the invoice by mail.
Name
First Name
Last Name
Email
example@example.com
Department Name of Where You Are Hired and Hire Date
Example: Tooele Fire Dept 01/01/2010
Please include: Date of Birth & Where You Were Born
Example: 01/10/1950 Salt Lake City, Utah
Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
example@example.com
Please list two Beneficiaries including your relationship to them along with a contact phone number
Example: Ben Salt, son 801-xxx-xxxx Cathy Salt, daughter 435-xxx-xxxx
Chief of Your Department and Their Email Address
Chief Mike Smith, email mike.smith@xxx.com
Signature
Submit
Should be Empty: