Chalfont Chemical Fire Company No. 1 Junior Membership Application

  • Chalfont Chemical Fire Company No. 1 Junior Membership Application

    * Applicants must be present at the Company's General Membership meeting when proposed for membership

  • Personal Information

  • Date of Application*
     - -
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Driver's License Expiration Date*
     - -
  • Have You Ever Been Convicted of a Crime Other Than Minor Traffic Offense?*
  • Have You Ever Been Arrested?*
  • What Area(s) Are of Interest?*
  • Format: (000) 000-0000.

  • School Information

  • Format: (000) 000-0000.

  • Prior Emergency Services Experience

  • Are You Now Or Were You Ever A Member Of Any Other Emergency Services Agency? If No, Please Continue To The Next Page.*

  • Health

  • How Would You Describe The General Condition of Your Health?*
  • Do You Have Any Physical or Mental Limitations That May Inhibit Your Ability To Perform Emergency Service Duties?*

  • Statement Of Understandings And Authorizations

    *A signature of Parent or Legal Guardian is required to complete this application

  • I hereby apply for membership in the Chalfont Chemical Fire Company No. 1, herein known as the the Company, and, if accepted for membership, I will comply with the constitution, bylaws, rules, standard operating procedures, and conduct expected of company members.

    I authorize the Company to investigate the statements made in this application. I understand that an investigation of these statements may be made, including but not limited to, a criminal background check and a Bureau of Motor Vehicles records check. I understand that omitting or falsifying information in this application or any subsequent interview connected with this application may result in denial of membership or expulsion from the Company.

    I hereby authorize the following parties to release any and all information concerning me to the Officers of the Company, or their agent:

    1. Bureau of Motor Vehicles of the Commonwealth of Pennsylvania or any other state driver's license authority;
    2. Any law enforcement agency;
    3. Any emergency services agency I was ever a member of;
    4. Any employer, past or present.

    I understand that nothing contained in this application or any membership interview is intended to create a contract for employment, a contract providing any benefit, or to in any way obligate the Company. I certify that no promises regarding employment or any other benefit made to me and I understand that in any event, any such promises are not binding on the Company.

    I acknowledge in the event of an injury, my remedy against the Chalfont Fire Company may be limited to a claim of Worker's Compensation.

    In accordance with the ESIGN Act of 2000, this application was completed and signed electronically; I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

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