Membership Application Form

Membership Application

Walker Valley Chemical Engine Company No. 1
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Resident Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number
Format: (000) 000-0000.
Past Medical History
Your medical history DOES NOT disqualify you in any way from joining the Walker Valley Fire Company. We ask for this information, so we are aware and can discuss your symptoms, management and treatment plans which helps us determin how you can be vital to this amazing team.
Employment Status
Place of Employment (If Applicable)

Name

Street Address

CityState / Province

Postal / Zip Code
Personal Reference Name

First NameLast Name
Who are they to You? - They Can not be Family
Reference Contact Details

Street Address

Phone Number

CityState / Province

Postal / Zip Code
How long have you known them?
What Position(s) are you interested in?
Have you belonged to another agency before?
If so, please put name of the Agency
Agency Name
Agency Contact Person

First NameLast Name
Agency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Leaving that Agency
Please put any Fire / Medical Training?
Example: CPR/AED, EMT, FF1, None, etc.
Have you been convicted of Arson?
Please fill out this section. If you are voted into the dept, we will use this information to set you up with dept messages and call dispatches via IAMResponding
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Provider (AT&T, Verizon, T-Mobile, etc.)
Primary Email
example@example.com
Emergency Contact

Full Name

Email

Phone NumberState / Province

Postal / Zip Code
Applicant Statement:

By signing below, I Certify that all information provided by me is true and complete to the best of my knowledge. I authorize investigation and background check required by New York State of all statements and refeennes which i have provided above. I understand this to be necessary in arriving to my membership decscion. In the event of membership approval, I understand that upon discovery of false or misleading information given in my application, or during any membership interview, may result in my discharge from membership. I also understand that i am required to follow all rules, regulations, policies, procedures, job requirtements which is stated in the Constituation and By-Laws of the Walker Valley Chemical Engine Company No. 1. I understand that failure to follow the listed above may result in my discharge from membership.
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Membership Application

Please fill out this section. If you are voted into the dept, we will use this information to set you up with dept messages and call dispatches via IAMResponding