Membership Application
Laurel Fire Company
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your interest in the Fire Company
Fire Fighter
Jr Fire Fighter
Fire Police
Social Member
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Were you ever or are you currently a member of another Fire or Ambulance Company?
Yes
No
If yes, where?
Can we contact them?
Yes
No
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Were you ever suspended or permanently removed as a member of a Fire or Ambulance Company?
Yes
No
If yes, why?
Have you ever been convicted of a crime?
Yes
No
If yes, when? Description of Conviction
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Employment Information
Current Employer
Employers Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Training Information
List any training that you may have pertaining to the Fire Services:
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References (No Relatives)
Name, Address, and Phone #
Name, Address, and Phone #
Name, Address, and Phone #
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Signatures
Applicant’s Signature:
*
Date
-
Month
-
Day
Year
Date
Proposed by:
Investigated by:
Accepted or Denied
Accepted
Denied
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: