Name:_________________________________ Date of Birth:_____________________

Address:_________________________ Mailing Address:________________________

City:____________________________ City:__________________________________

State:_________ Zip Code:__________ State:____________ Zip Code:_____________

Home Phone:__________________________ Work Phone:_______________________

Cell Phone/ Pager:______________________ Email address:______________________

Drivers License NO:____________________ Social Security:______________________

Active Membership:__________________ Contributing Membership:_______________

Previous Fire Training:________________________________________________________________

Membership with other Fire Companies:_______________________________________

Special Interest: Fire Fighting:___________ Truck Maintenance:___________________

Dive Team:__________ Building Maintenance:___________ Administration:________

Emergency Contact:

Name Relationship Phone Number

Recommended by:________________________________________________________

Active Members are proposed at one company meeting and voted for approval at the next meeting. Dues for the first year are $5.00 and must accompany this application and $2.00 thereafter if Active Status is maintained

Minimum Age: 14 years (anyone under 18 years must have working papers).