PERSONAL
Membership Type
Select Membership
Firefighter
Fire Police
Administrative
Auxiliary
Driver
Emergency Medical Services
Date of Birth
Last Name
Date
First Name
E-mail Address
MI
Street Address
City, State, Zip
How long have you lived at this address?
Home Phone
Business Phone
Sex (M/F)
If you were in the Armed Forces, when were you discharged? Month/Year
Are you over 18 years of age?
Have you ever been convicted of a traffic violation, misdemeanor, or a felony
If Yes, indicate the date and nature of the charge, police agency, court and disposition.
PARENTAL INFORMATION (Required For Junior Membership)
First Name
Last Name
Phone Number 1
Phone Number 2
EXPERIENCE
Have you ever filed an application Kimberton Fire Company?
If so, when?
Have you ever been denied membership to a fire and/or rescue squad?
If so, please give details.
Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire and/or rescue department?
If so, please give details.
List any fire fighting and/or emergency medical certifications that are current. Please provide copies of certifications
Certifications
State
EDUCATION
High School attended
Location (City/State)
Did you graduate or receive a GED?
Date graduated, or received GED
College or University
Location (City/State)
Dates attended
Major or Degree awarded
MEDICAL HISTORY
Have you ever...
had an operation?
Select Answer
No
Yes
been seriously injured?
Select Answer
No
Yes
been refused employment for reasons of health?
Select Answer
No
Yes
been forced to resign from a job or volunteer position for health reasons?
Select Answer
No
Yes
fractured any bones or dislocated any joints?
Select Answer
No
Yes
been refused life insurance?
Select Answer
No
Yes
been diagnosed with an illness caused by your job or volunteer position?
Select Answer
No
Yes
injured your back?
Select Answer
No
Yes
suffered from lung problems?
Select Answer
No
Yes
suffered from heart problems?
Select Answer
No
Yes
suffered from swelling of the legs or ankles?
Select Answer
No
Yes
suffered from fainting spells or dizziness?
Select Answer
No
Yes
suffered from frequent headaches?
Select Answer
No
Yes
been hospitalized or on medication for mental illness?
Select Answer
No
Yes
Do/are you...
currently wearing glasses?
Select Answer
No
Yes
using a hearing aid?
Select Answer
No
Yes
on any medications?
Select Answer
No
Yes
If you answered yes to any of the above, please provide more information.
REFERENCES
Please list 3 references, not related to you by blood, adoption, or marriage, which you have known for at least one year.
NAME
ADDRESS
WORK PHONE #
HOME PHONE #
Please provide any previous fire departments or rescue squads that you have been a member of:
DEPARTMENT
ADDRESS
CHIEF OFFICER
PHONE NUMBER
Please provide any previous fire departments or rescue squads that you have been a member of:
EMPLOYER
SUPERVISOR
OCCUPATION
PHONE NUMBER
Do you give permission for us to contact your supervisor?
Select Answer
No
Yes
Drivers License Information:
Drivers License #
State Issued
ACKNOWLEDGEMENT
I authorize investigation of all statements in this application. I understand that misrepresentation of omission of facts is cause for dismissal. Further, I understand and agree to abide by all rules and regulations governing the Kimberton Fire Company.
I also agree to successfully complete or provide proof of successful completion of a Firefighting I course within one year of membership. Failure to do so is cause for dismissal.
Applicants under 18 years of age must supply the Kimberton Fire Company with working papers at time of application for membership. You must also have the "Parental Information" section above completed by a parent or guardian. Please note that cash, check or money order payable to Kimberton Fire Company for $5.00 for membership dues.
In connection with my application for membership with the Kimberton Fire Company, I understand the investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports may include information reflecting upon my character, work habits, performance and experience. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil and other experiences. I authorize, without reservation, any party or agency contacted by this organization to furnish the above mentioned information. membership@kimbertonfire.org .
Please type your signature here:
Who may we thank for referring you?
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