Fire Department Application
Dear Applicant,
In order to better evaluate your application for membership to the Medway-Grapeville Fire Company, please provide us with the following information.
What type of membership are you applying for?
Active
Social
What is your name?
*
First Name
Middle Name
Last Name
Suffix
What is your address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your email address?
*
example@example.com
What is the best phone number to reach you?
*
-
Area Code
Phone Number
What is your date of birth?
*
-
Month
-
Day
Year
Date
What city and state were you born in?
*
What is your Drivers License Number?
What is your Driver's License Expiration Date?
-
Month
-
Day
Year
Date
What is your Social Security Number (Please enter as nine digits, no dashes)
*
Have you ever been, or are you now an active member of a New York State Volunteer Fire Company or Department?
*
Yes
No
If yes, which department or company?
Have you ever applied for membership in the Medway-Grapeville Fire Co.?
*
Yes
No
If yes, when?
Have you ever been convicted of a felony?
*
Yes
No
If yes, please provide details
In the past three years, have you received any traffic violations?
*
Yes
No
If yes, please provide details
Do you have any physical disabilities?
*
Yes
No
If yes, please explain
Parent/Guardian Consent: If you are under the age of 18, parental or guardian consent is required to apply for membership.
First Name
Last Name
All information will be held in the strictest confidence. Any false or misleading information given in this application may be considered grounds for denial or dismissal.
I swear that the above information is true to the best of my knowledge, so signed:
*
Submit
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