Name * First Name Last Name Email * Type of Membership * Active Member Social Member Junior Member (Under 18 Years Old, Will Need Legal Guardian Consent) Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Home Phone (###) ### #### Cell Phone (###) ### #### Social Security Number Drivers License Number Employer Name * Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Phone * (###) ### #### Prior Experience * Have you been or currently a member of another emergency service organization(s)? Yes No If Yes Name of Organization Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Positions held Chief Name Chief Phone (###) ### #### Qualifications List applicable fire and EMS classes / certificates and upload copies. Hard copies can also be brought to the station. May the Wayne Township Volunteer Fire Company contact your current or past organizations? * Yes No If no, please explain Have you ever been dismissed or forced to resign from any position / organizations? * Yes No If yes, please explain. Have you ever beeen arrested, indicted, convicted, fined, imprisoned or placed on probation or has any case been filed against you? * Yes No If yes, please explain. Do you have any medical impairment that would limit your activities in the fire company? * Yes No If yes, please explain. References List three references excluding relatives or members of the Wayne Township Volunteer Fire Company. Name * First Name Last Name Phone * (###) ### #### Name * First Name Last Name Phone * (###) ### #### Name * First Name Last Name Phone * (###) ### #### The Wayne Township Volunteer Fire Company is an equal opportunity organization and does not discriminate based on race, creed, religion, sex, sexual orientation, national origin, age, or any other characteristics protected by law. All applicants are subject to an interview by the fire company membership committee and a background check by the Pennsylvania State Police. All applicants should endeavor to familiarize themselves with the fire company and its members. Applicants who are accepted as members must complete a one year probationary period to demonstrate an interest in participation. I verify the information I have provided to be true and accurate. I understand the submission of false information may terminate my application and membership. I hereby authorize the Wayne Township Volunteer Fire Company to make inquiries to any individuals, police agencies, employers, references or emergency services organizations during the investigation into my background Yes No Name * First Name Last Name Date * MM DD YYYY Congratulations! You have just completed the first step towards membership. Check the events calendar on the website to find the next training night or monthly meeting. New members must pay a $10 application fee and attend at least 1 monthly meeting prior to application approval. Someone should reach out shortly to let you know your application has been received.
