RICHFORD FIRE DEPARTMENT

APPLICATION FOR MEMBERSHIP

Date: ________________________

Positions Applying For:

Interior Fire Fighter _______ Exterior Fire Fighter _______

Certified First Responder ________ Fire Police __________

General Help _______ Building Maintenance _______

Name: __________________________________________________________

Address: ________________________________________________________

Home Phone # ___________ Work Phone # ____________

Cell Phone # ____________ Email Address ____________________________

Social Security # __________________ Driver’s License # ____________

How long have you resided at the above address? Years _____ Months _____

Are you eighteen years of age or older? Yes __ No __ Date of Birth ________

Have you ever been known by any other name? Yes __ No __

If yes, list name (s) and reason (necessary to enable a check on your application)

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Do you have any traffic violations currently on your license? Yes __ No __

If yes, please list offense and date of offense?

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Except for minor traffic violations and adjudications as a youthful offender, have you ever been convicted of a crime? Yes __ No __

If yes, give particulars of each charge on an additional attached sheet.

Please list the names and phone numbers of any acquaintances that are members of this organization.

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All information contained/or obtained herein will remain confidential.

Signature: ______________________________________

Date: __________________________________________

Witness: _______________________________________

Date: __________________________________________

Sworn and subscribed to before me

the ______________ day of ________________________, 200__.

_________________________________

Notary Public

Secretary’s Endorsement

This application, accompanied by the $5.00 initiation fee, was received and read at a regular meeting of the Richford Fire Department, Inc. held on the ____________ day of _________________, 200 __.

This application was approved by the membership at regular meeting of the Richford Fire Department, Inc., held on the ___________ day of _________________, 200 __ by a majority vote of the membership.

_______________________________ Secretary