Application for Membership

North Fayette Township VFD Membership Application

General Information

Full Name:

Date of Birth:

Email:

Phone Number:

Home Address (Street, City, State, Zip):

Next of Kin Name:

Relationship:

Next of Kin Phone:

Beneficiary:

Membership Type Desired:

Membership Types Explained:

Active Member: Full operational firefighter, responds to calls and participates in training.
Associate Member: Non-operational support roles including fundraising and community outreach.
Special Active Member: Limited operational duties due to work, school, or location.
Junior Member: Ages 14-18, participating in training and limited activities under supervision.

Emergency Contact Information

Emergency Contact Name:

Relationship:

Emergency Contact Address (Street, City, State, Zip):

Home Phone:

Cell Phone:

Email Address:

Education

High School and/or College (Name, Dates, Graduation, Degree):

Work Experience

Employer Name & Address:
Position Held:
Dates Employed:
Supervisor Name & Phone:
Disciplined at Work? (Y/N):
If Yes, explain:

Driver’s License Information

License Class:

State:

Operator’s Number:

Expiration Date:

Restrictions (if any):

License Revoked/Suspended?

If Yes, explain:

Fire/EMS Department Experience

Organization Name:
Position Held:
Dates Active:
Chief’s Name & Phone:
Certifications (list all):

Criminal History

Convicted of a misdemeanor or felony?
If Yes, explain:

Health Record

Can perform essential functions?

Need accommodations?

If accommodations needed, explain:

Medical History:

Allergies:

Medications:

Hepatitis Vaccination?

Wear Glasses/Contacts?

Professional/Character References

Please list three references (not relatives).

Reference 1 (Name, Phone, Years Known, Email, Address):
Reference 2 (Name, Phone, Years Known, Email, Address):
Reference 3 (Name, Phone, Years Known, Email, Address):

I certify that the statements made by me in this application and any supplements are true and correct to the best of my knowledge. I authorize the North Fayette TWP. VFD to verify such answers and contact all references. I understand that any false statements on the application or supplements to it may be considered sufficient cause for rejection of this application or for dismissal. I also promise to abide by the rules and bylaws of the NFTVFD.