Kimberton Fire Company
Kimberton Fire Company
Kimberton Fire Company

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Membership Application

Required   Indicates Required Field
APPLICANT INFORMATION
First Name : Required
Middle Name :
Last Name : Required
Date of Birth : Required
Date of Application : 07/19/2024 0045
Are you at least 18 years old: Required No
Yes
Are you Married: Required No
Yes
If you are married, what is your spouse's name:
HOME ADDRESS
Street Address : Required
City: Required
State: Required
Zip Code: Required
CONTACT INFORMATION
Cell Phone :
Cell Carrier :
(i.e. Verizon, AT&T, T-Mobile)
Alternate Phone :
Alternate Phone Type:
Email Address: Required
Last Four Numbers of your Social Security Number:
Drivers License Number:
Drivers License Issuing State:
EMPLOYER INFORMATION
Business Name : Required
Business Address:
Position:
Supervisor Name :
Business Phone:
POSITION of INTEREST
Please indicate the position you are interested in volunteering for: Required Fire Fighter
Fire Police
Junior Fire Fighter - (14 – 17 Years Old)
Support / Administrative
EMERGENCY SERVICES EXPERIENCE
Are you currently, or have you ever been, a member of another Emergency Services Organization: Required No
Yes
Company Name :
Officer-in-Charge :
Department Position:
Dates of Service :
Current Member : No
Yes
If No, Reason for Leaving :
Company Name #2:
Officer-in-Charge #2:
Position #2:
Dates of Service #2:
Current Member #2: No
Yes
If No, Reason for Leaving #2:
Summary of emergency service and/or certifications:
MILITARY SERVICE
Are you currently, or have you ever been, a member of the armed services: Required No
Yes
PERSONAL SKILLS or QUALIFICATIONS
Note any special skills and qualifications that may be helpful to the organization:
EDUCATION
Please indicate your level of education: High school or GED
If you did not complete high school, highest grade completed :
School name:
Address:
MEDICAL HISTORY
Do you have any physical or medical limitations that would affect your performing as a firefighter or fire police officer: Required No
Yes
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: Required
Emergency Contact Phone Number: Required
Emergency Contact Street Address : Required
Emergency Contact Relation: Required
Emergency Contact Phone Home Number: Required
Emergency Contact Phone Mobile Number: Required
Emergency Contact Phone Work Number: Required
REFERENCES - List three people who are not related to you
Reference #1 Name: Required
Reference #1 Phone Number: Required
Reference #1 - How do you know them: Required
Reference #2 Name: Required
Reference #2 Phone Number: Required
Reference #2 - How do you know them: Required
Reference #3 Name: Required
Reference #3 Phone Number: Required
Reference #3 - How do you know them: Required
ADDITIONAL INFORMATION
Have you ever been denied membership to an Emergency Services Organization: Required No
Yes
Have you ever been discharged from an Emergency Services Organization: Required No
Yes
AGREEMENT AND SIGNATURE
Please type your signature here: Required
APPLICIANTS UNDER 18 of AGE
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.
Parent or guardian please type your signature here:
  • 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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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
Donuts: 610-935-1388 EXT 4
E-mail: secretary@kimbertonfire.org
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