SRVFC Membership Application

Slippery Rock Volunteer Fire Company & Rescue Team

Requirements of Membership: All members must have or obtain a sponsoring member. All members are expected to run calls. All members must participate in all company fundraisers. All members are required to complete an orientation in a timely manner. Any member convicted of drug charges or a felony offense will be automatically expelled. All members must maintain a clean and professional appearance. All applicants must meet with the membership committee before his/her first reading. A six month probation period will be observed. All members will be required to complete a minimum of 30 hours of training per year.

goo.gl/giR6Pv Application received by:

Date

Name first middle last

Maiden Name

Permanent Address

Home Phone

Cell Phone

Date of Birth

Date

EMail

example@example.com

SS Number

WILL ONLY BE USED TO FACILITATE BACK GROUND CHECK AND VOIDED AFTER.

Sponsoring Members Name

Emergency Contact Information: name, phone #, and relationship

Emergency Contact

Phone #

Relationship

Students only: College Address Parent's Name

Parents Name

College Address

Phone

Please circle the type of membership you are applying for: (read descriptions below) Applicants applying for active must live or work within the Slippery Rock Fire District. (Live=permanent address)

Active - 18 years and older and live or work in the fire district Jr. Fire Person - 16-18 years old and live or work in the fire district (NEED WORKING PAPERS WITH APPLICATION!) Temporary Active - 18 years and older being a temporary resident of fire district (College Students/ Live In Members Social - Non-active participant over 21 years old. Please attach a $10.00 membership fee. (Circle)ActiveJr. Fire Person Temporary Active What is your interest? Firefighting

After your application has been received and processed , you will be notified to complete a drug test. This is at no cost to you.

List any previous experience with Fire, EMS, or public service organizations.

	Organization	Address	Phone #	Position/ Rank	Date as a memeber	Chief Officer
1
2
3

List all specialized training include certification number if applicable and include a copy of all certificates attached to this application

List any other skills or qualifications you have trade legal financial secretarial language etc

Medical History: Do you have any physical or mental impairment that would prevent you from fulfilling the duties and expectations associated with being a member of this organization? This includes handling physically strenuous activity. (Circle) Yes or No

No

If yes please explain

No

If so please explain and note the state where it occurred

Criminal History: Have you ever been convicted of a felony or misdemeanor? (Circle) Yes or No If so please explain and note the state where it occurred:

Occupational Information: Occupation: Employer: Address:

Occupation

Employer

Phone #

Address

Supervisors Name

High School Diploma?

Have you served in the Military?

Branch

Rank

Number of years served

Honorable discharge?

List two references that are not the sponsoring member, significant other or your relative. (name, city/state, phone) 1.

1

2

I understand the requirements and obligations of membership and by my signature, I accept all conditions. I understand that the omission of, or falsification of any information on this form may automatically disqualify me from membership eligibility.

Signature

Date

Sponsoring Member's Signature: *You must have a sponsoring member for your application to be read.

Sponsoring Members Signature

If you are under the age of 18 you must have a parent/guardian signature. I givemy permission to actively participate at the Slippery Rock Volunteer Fire Company & Rescue Team's training, fundraising and calls.

I give

Signature

Date