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| APPLICANT INFORMATION |
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| First Name :
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| Middle Name :
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| Last Name :
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| Date of Birth :
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| Date of Application :
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05/19/2024 1201 |
| Are you at least 18 years old: |
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No
Yes
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| Are you Married: |
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No
Yes
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| If you are married, what is your spouse's name:
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| HOME ADDRESS |
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| Street Address :
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| City:
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| State:
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| Zip Code:
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| CONTACT INFORMATION |
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| Cell Phone :
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Cell Carrier :
(i.e. Verizon, AT&T, T-Mobile)
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| Alternate Phone :
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| Alternate Phone Type:
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| Email Address:
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| Last Four Numbers of your Social Security Number:
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| Drivers License Number:
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| Drivers License Issuing State:
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| EMPLOYER INFORMATION |
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| Business Name :
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| Business Address:
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| Position:
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| Supervisor Name :
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| Business Phone:
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| POSITION of INTEREST |
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| Please indicate the position you are interested in volunteering for:
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Fire Fighter
Fire Police
Junior Fire Fighter - (14 – 17 Years Old)
Support / Administrative
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| EMERGENCY SERVICES EXPERIENCE |
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| Are you currently, or have you ever been, a member of another Emergency Services Organization: |
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No
Yes
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| Company Name :
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| Officer-in-Charge :
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| Department Position:
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| Dates of Service :
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| Current Member : |
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No
Yes
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| If No, Reason for Leaving :
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| Company Name #2:
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| Officer-in-Charge #2:
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| Position #2:
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| Dates of Service #2:
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| Current Member #2: |
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No
Yes
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| If No, Reason for Leaving #2:
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| Summary of emergency service and/or certifications:
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| MILITARY SERVICE |
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| Are you currently, or have you ever been, a member of the armed services: |
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No
Yes
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| PERSONAL SKILLS or QUALIFICATIONS |
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| Note any special skills and qualifications that may be helpful to the organization:
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| EDUCATION |
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| Please indicate your level of education:
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High school or GED
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| If you did not complete high school, highest grade completed :
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| School name:
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| Address:
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| MEDICAL HISTORY |
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| Do you have any physical or medical limitations that would affect your performing as a firefighter or fire police officer: |
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No
Yes
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| EMERGENCY CONTACT INFORMATION |
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| Emergency Contact Name:
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| Emergency Contact Phone Number:
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| Emergency Contact Street Address :
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| Emergency Contact Relation:
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| Emergency Contact Phone Home Number:
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| Emergency Contact Phone Mobile Number:
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| Emergency Contact Phone Work Number:
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| REFERENCES - List three people who are not related to you |
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| Reference #1 Name:
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| Reference #1 Phone Number:
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| Reference #1 - How do you know them:
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| Reference #2 Name:
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| Reference #2 Phone Number:
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| Reference #2 - How do you know them:
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| Reference #3 Name:
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| Reference #3 Phone Number:
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| Reference #3 - How do you know them:
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| ADDITIONAL INFORMATION |
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| Have you ever been denied membership to an Emergency Services Organization: |
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No
Yes
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| Have you ever been discharged from an Emergency Services Organization: |
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No
Yes
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| AGREEMENT AND SIGNATURE |
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| Please type your signature here:
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| APPLICIANTS UNDER 18 of AGE |
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| Applications under 18 of age must supply the Kimberton Fire Company with working papers at time of application for membership. Also, the following section must be completed by a parent or guardian. |
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| Parent or guardian please type your signature here:
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- By submitting this application, I affirm that the facts set forth in are true and complete. I understand if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
- I understand and agree to abide by all rules and regulations governing the Kimberton Fire Company.
- If applying for Fire Fighter, I understand I am expected to complete Fire Fighter I training within one year of submission of this application.
- I authorize the Kimberton Fire Company to investigate any and all information in this application and hereby authorize the named references to disclose such information, personal or otherwise, as requested during the investigation. I agree to release all parties from liability as a result of the disclosure of the requested information.
- I understand that, if accepted, my membership is governed by the bylaws and the Standard Operating Guidelines of the Kimberton Fire Company.
- I understand that annual dues are $5.00 and are to be paid by January each year, for continued membership.
- I understand that I must submitted the following background checks with this application.
Act 34 PA Criminal Record Certificate online
Act 151 PA Child Abuse History Certificate online
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