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Your Full Name (First, Middle, Last, Suffix): *
Your Address: *
City
State: AL AK AR AZ CA CO CT CZ DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Choice 58
Zip Code:
Telephone (Current Home):
Telephone (Current Cell Phone): *
Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
be past Chief's
Social Security Number:
Driver's License Number: *
Driver's License State: Driver's License State: AL AK AR AZ CA CO CT CZ DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Choice 58
Driver's License Expiration Date:
High School Attended (Please indicate highest grade completed):
College Attended:
Degree / Educational Concentration:
Interest Area (Administration, Communications, Emergency Medical Service [EMS], Explorer Program, Fire, Fire/EMS, Fire Police, Fundraising, Other:
Location of the Fire Company / Department?
Chief's Name and Phone Number:
List Any Experience (Bring any/all certifications to interview):
Do you have any health / physical conditions that would interfere with you providing emergency service? Yes (please fill out next question) No (Please skip next question)
Please provide your family physician's name and phone number.
Please describe any health or physical conditions that would interfere with providing emergency services:
Are you taking any medications on regular basis? If so, please provide a list.
Emergency Contact (Please provide Name and Best Method of contact):
Please include all summaries, misdemeanors, felonies, and traffic history:
List 3 People (including Name, Phone, and Address) not related to you that have known you for more than 3 years:
I authorize the Loyalsock Volunteer Fire Company to perform any additional criminal background check on my behalf and understand it is my responsibility to complete such forms to include the same information regarding my past criminal history as a requirement for membership. In addition, I authorize Loyalsock Volunteer Fire Company to contact my list of references provided as part of my character makeup prior to and following membership interview.. Yes No
I hereby acknowledge and understand there is a $10.00 non refundable administration/application fee due prior to or at the time of membership interview. Administration/Application fee can be made payable by check (Loyalsock Volunteer Fire Company) and mailed with attention to Membership Committee, Loyalsock Volunteer Fire Company, 715 Northway Road, Williamsport PA 17701 with applicant name in the For or Subject area of the check. Yes No
I understand that during the membership interview, additional questions, forms, and documenation may be required to complete my membership application. Yes No
I hereby acknowledge all information filled out in the above sections to be correct and fully accurate. Any failed or false information will be documented and open to disclosure during interview process. If you accept the terms and conditions, please digitally type in your full name and click submit below.
