BEC Membership Application

Education Information
Highest Grade Completed/Enrolled*

5678High SchoolTechnical SchoolCollege/UniversityGraduate School
High School Information
Name of High School
Address of High School
(City & State only)
Date Graduated
(If still attending, type in "attending")

References

List three people who are not related to you by blood or marriage who are familiar with your education or work experience who may be contacted by committee
Reference 1
Name:*

First NameLast Name
Phone Number*
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:

First NameLast Name
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 3
Name:

First NameLast Name
Phone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
May we contact any or all of your listed above references*

YesNo

Emergency Services Experience
Have you ever been a member of a fire department, rescue squad, or similar organization*

YesNo

Arrest's / Summons
Have you ever been arrested, summoned into court as a defedant or indicted, convicted, fined, imprisoned or placed on probation, or has any case been filed against you*

YesNo
If Yes, Please Explain
Have you ever been ordered to deposit collateral for alleged breach or violation of any order, ordinance, or police regulation whatsover*

YesNo
I authorize investigation of all statements on this application. I understand that misrepresentation or omission of facts called for, is cause for dismissal. Further, I understand and agree that my acceptance is dependent upon the successful completion of a physical examination, and police background check.
Signature*

Clear
Drivers License Number
State
Date
Date of Submission

MonthDayYear
Date
Should be Empty:

Applicant Information