Kimberton Fire Company
Kimberton Fire Company
Kimberton Fire Company

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Join The Kimberton Fire Company!

Use the form below to apply for membership to the Kimberton Fire Company. After completing this form, a representative of the membership committee will contact you. In the meantime, feel free to come down and visit the stations.

Submission of this form represents permission for the Kimberton Fire Company to conduct a background check using the information supplied

PERSONAL
Membership Type
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?
  been seriously injured?
  been refused employment for reasons of health?
  been forced to resign from a job or volunteer position for health reasons?
  fractured any bones or dislocated any joints?
  been refused life insurance?
  been diagnosed with an illness caused by your job or volunteer position?
  injured your back?
  suffered from lung problems?
  suffered from heart problems?
  suffered from swelling of the legs or ankles?
  suffered from fainting spells or dizziness?
  suffered from frequent headaches?
  been hospitalized or on medication for mental illness?
       
Do/are you... currently wearing glasses?
  using a hearing aid?
  on any medications?
       
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?  
       
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.
Agree by placing your initials in box to the right  

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.
Agree by placing your initials in box to the right  

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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Kimberton Fire Company
Physical Address: 61 Firehouse Lane
GPS Address: 2276 Kimberton Road
Kimberton, PA 19442
Emergency Dial 911
Non-Emergency: 610-935-1388
Station Fax: 610-935-3956
Auxiliary/Donuts: 610-935-1388 EXT 4
E-mail: kfc@kimbertonfire.org
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