Application for Membership

This Applicant is Applying For:(Required)

Name(Required)

Address(Required)

Home Phone Number(Required)

Work Phone Number

Email(Required)

Cell Phone Number

Emergency Contact Information

Name(Required)

Relationship(Required)

Phone(Required)

Do you presently have a valid driver's license?

Yes

State

License Number

Current Class

CDL?

Yes

Restrictions?

Yes

Has your lisence ever been expired or revoked?

Yes

If yes, please explain why:

Please list three (3) references or individuals with whom you have been associated for the last three years.

Name

Phone

Address

Street Address City State ZIP Code

Name

Phone

Address

Street Address City State ZIP Code

Name

Phone

Address

Street Address City State ZIP Code

Have you ever applied for membership with the Collingdale Fire Company?

Yes

If yes, when and your reason for leaving:

Do you now or have you ever held a membership with any other fire company or rescue organization?

Yes

If yes, please list when and with whom. Please list all current / former companies / associations:

Do you have any friends or relatives that are now or have been members of Collingdale Fire Company?

Yes

If yes, please list them; not more than four:

Have you ever been arrested, convicted of a felony or misdemeanor or had a court ordered judgement against you?

Yes

If yes, please explain below:

Do you now, or in the past, have any known medical problems?

Yes

Are you currently under a doctor's care for any conditions?

Yes

Do you presently take any medication for a medical or any other conidtion?

Yes

If you answered yes to any of the above, please explain:

If you had any training in firefighting or emergency medical services, please list your training. If you are an EMT or a Paramedic, please list your certification number.

Fire Training:

Emergency Medical Training:

Age of Applicant(Required)

Signature(Required)

I, the undersigned, being the above years of age, do make application to this organization. If accepted, I agree to comply with all of the rules, regulations, Constitution and By-Laws of the Collingdale Fire Company – Station 33. I have read the initial statement regarding the truthfulness of my answers on this application, and I also understand the fire company’s policy of being placed in a (6) six-month probationary period. I further understand the company will conduct the standard background investigations and has my written permission in the form of my signature. I further agree to hold this company harmless and assume full responsibility for any pre existing medical condition whether known to me or not.

Signature of parent or guardian if the named applicant is at least 14 and less than 14 years of age:

Relationship

Date

Signature of fire company sponsors for the trainee / cadet membership:

Date

Signature of fire company sponsors for the trainee / cadet membership:

Date

Name

This field is for validation purposes and should be left unchanged.

Collingdale

Fire Company

We are currently accepting resumes for Emergency Medical Technician.

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY:

Emergency Contact Information

Collingdale Fire Company

Phone