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Hemlock Farms Volunteer Fire & Rescue Company

Application for Membership

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You may be required to lift, carry, or climb ladders, or to perform other tasks that involve physical exertion. Do you have any medical conditions that will prevent you from performing these tasks? If yes, a doctor's note may be required.
Relationship
Military Service
Yes
No
Branch
Active Duty?
Yes
No
Have you ever been convicted of a crime/felony?
Do you have any recent traffic offenses/accidents?
May we contact your supervisor?
Have you ever belonged to another fire/rescue company?
May we contact them?

Supply the name, address, and phone number of 2 personal references (not related).

I authorize an investigation of all statements contained in this application, along with a background check, and understand that any omission or misrepresentation of facts is a cause for dismissal.

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Date
Month
Day
Year

If the applicant is under 18 years of age, a parent/guardian is required to fill in the following:

Applicant Birth Date
Month
Day
Year

I hereby signify that I am the parent/guardian of the above-named applicant. He/She has my consent and approval to be a member of the Hemlock Farms Volunteer Fire & Rescue Company and to engage in the usual activities of membership.

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Relationship
Date
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