Cover Letter – To be given to applicant Page 1 of 2
South Media Fire Company #1 - STATION 51
535 - Washington Street - Media, Pennsylvania 19063
Applicants: - Active – Administrative – Contributing
Cadet - & Junior Members – See notes on back of this page.
( Circle desired classification applying for in 1st section of application )
All questions on the application must be answered in full in order to be submitted.
There is a $1.00 INITATION FEE to be paid at time of submitting application.
When filling out the Application and any other paperwork, all information must be,
TYPED & / or PRINTED.
The only exception to the above sentence is when a “signature is required”. Please try to write signature so it can be read.
It is very difficult for the person trying to submit your Application and other information at a meeting when they cannot read what is on the paperwork.
By not following the above outline this could cause a delay in presenting your application to the Company at a meeting.
Background check form :
This form is to be completed, including your signature and printing your name down to where it says
“POLICE DEPT. REPRESENTATIVE”
This section will be completed by the Nether Providence Township Police Department.
As stated on background check form – “FINGERPRINTS” - are required. You can make arrangements with the Police Dept. to have this done.
Upon being voted in there will be other paperwork that has to be completed.
Thank You
Membership Committee
Page 2 of 2
Cadet Members – Age 14-15 Years of age
Junior Member – Age 16 to 17 Years of age
Cadet and Junior Applicants along with their PARENT &/Or Guardian shall meet with the Membership Committee prior to their application being submitted to the Fire Company at a regular stated meeting.
Application shall be completed as outlined.
EXCEPTION:
As stated on Application, Parent &/or Guardian of Cadet and Junior Applicants shall sign their name at time of interview with the Membership Committee.
Disclosure Form – Parent &/or Guardian of Cadet and Junior Applicants shall sign
their name at time of interview with Membership Committee.
South Media Fire Company #1 - STATION 51
535 - Washington Street - Media, Pennsylvania 19063
Membership Application
PLEASE PRINT OR TYPE AND FILL IN ALL INFORMATION COMPLETELY
======
DATE APPLICANT COMPLETED APPLICATION - ______
DATE MEMBERSHIP COMMITTEE RECEIVED ______INITIATION FEE PAID ______
DATE
DATE PROPOSED TO COMPANY - ______
DATE OF VOTE - ______- “ PROVISIONAL ” - ACCEPTED _____ REJECTED _____
DATE OF VOTE - ______- “ FULL MEMBERSHIP “ - ACCEPTED _____ REJECTED _____
CLASS OF MEMBERSHIP APPLYING FOR - ACTIVE CREW- ADMINISTRATIVE - CONTRIBUTING- JUNIOR
CADET
NAME: ______
LAST FIRST MIDDLE
ADDRESS:______
NUMBER AND STREET CITY STATE ZIP
PHONE: - HOME - ______CELL - ______WORK - ______
DATE OF BIRTH: ______S.S. NO.______6. BLOOD TYPE ______
PERSONS UNDER THE AGE OF EIGHTEEN ( 18 ) YEARS, APPLYING FOR JUNIOR MEMBERSHIP, MUST
HAVE A PARENT OR GUARDIAN SIGN HERE: ( TO BE SIGNED AT INTERVIEW )
______-______
PRINT SIGNATURE
DRIVERS LICENSE # - ______CLASS # ______CODES ______
VETERAN: YES _____ NO _____ TYPE OF DISCHARGE ______
U. S. CITIZEN: YES _____ NO _____ OCCUPATION ______
EMPLOYER: ______
ADDRESS: ______
NUMBER AND STREET CITY STATE ZIP
ARE YOU NOW A MEMBER OF ANOTHER FIRE COMPANY ? YES _____NO _____ IF YES COMPLETE BELOW
IF YES COMPLETE INFO BELOW :
NAME OF FIRE COMPANY: ______
ADDRESS: ______
NUMBER AND STREET CITY STATE ZIP
YEARS SERVED:______CHIEF AT TIME OF LEAVING CO. ______
REASON FOR LEAVING: ______
______
IF YOU HAVE EVER BEEN A MEMBER OF ANY OTHER FIRE COMPANY, PLEASE WRITE THE NAME OF
COMPANY AND OUTLINE THE SAME INFORMATION AS ABOVE ON PAGE 3. ALSO ON PAGE 3 OUTLINE
ANY OTHER INFORMATION YOU WOULD WANT THE FIRE COMPANY TO KNOW ABOUT YOU.
LIST ANY SPECIAL FIRE TRAINING OR ANY OTHER TRAINING YOU MAY HAVE TAKEN, AND LIST THE
CLASSES ON THE APPROPRIATE FORM. YOU MUST PRESENT COPIES OF ALL COMPLETION
CERTIFICATES & / OR LETTERS OF COMPLETION. USE ATTACHED FORM & SIGN.
STATE BRIEFLY, THE REASON YOU WANT TO JOIN S.M.F.C.
______
______
HAVE YOU EVER BEEN ARRESTED AND CONVICTED OF / OR PLEADED GUILTY TO ANY CRIME ?
YES ______NO ______IF YES EXPLAIN ON SEPARATE SHEET
HAVE YOU EVER BEEN CONVICTED OF THE OFFENSE OF DRIVING UNDER THE INFLUENCE OF
ALCOHOL OR DRUGS ? YES ______NO ______IF YES EXPLAIN ON SEPARATE SHEET
MEMBERS KNOWN IN S.M.F.C. - 1. ______2. ______
3. ______4 . ______5. ______
LIST THREE PEOPLE WHO CAN BE CONTACTED AS PERSONAL REFERENCES.
( PLEASE DO NOT LIST RELATIVES, I.E., PARENTS, BROTHERS, SISTERS , ETC. )
1. ______
2. ______
3. ______
NAME ADDRESS PHONE NUMBER
SIGNATURE OF SPONSOR: ( REQUIRED ) -______
DO YOU HAVE ANY PHYSICAL OR MENTAL IMPAIRMENTS ? YES ______NO ______
ARE YOU CURRENTLY UNDER A DOCTORS CARE OR TAKING PRESCRIPTION MEDICATION ? YES__ NO __
DATE OF LAST PHYSICAL - ______
ARE YOU WILLING TO UNDERGO A PHYSICAL EXAM PRIOR TO ACCEPTANCE ? YES _____ NO _____
DUTY RESTRICTION INFORMATION: SWIM - YES _____ NO ______---- PHOBIAS - YES _____ NO ____
ALLERGIES ? ______
PHYSICAL IMPAIRMENTS: MEDIC ALERT ? YES____ NO ____ = GLASSES ? YES ____ NO ____
I CERTIFY THAT ALL STSTEMENTS ON THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. YOU HAVE PERMISSION TO CONTACT PERSONS LISTED ON THIS APPLICATION.
______- ______
NAME - PRINT NAME - SIGNATURE
LIST ANY SPECIFIC FIRE TRAINING OR ANY OTHER INFORMATION YOU MAY WANT THE FIRE COMPANY MEMBERSHIP TO KNOW ABOUT
I CERTIFY THAT ALL STATEMENTS ON THE APPLICATION AND OTHER PAPERWORK ARE TRUE AND CORRECT TO THE BET OF MY KNOWLEDGE. YOU HAVE MY PERMISSION TO CONTACT PERSONS LISTED ON THE APPLICATION AND ANY OTHER CONTACTS YOU WISH TO MAKE.
______
APPLICANT NAME – PRINT APPLICANT NAME – SIGNATURE
South Media Fire Company #1 - STATION 51
535 - Washington Street - Media, Pennsylvania 19063
AUTHORIZATION FOR DISCLOSURE TO GENERAL MEMBERSHIP OF THE SOUTH MEDIA FIRE COMPNY NO. 1
I, ______, HEREBY AUTHORIZE FULL AND
NAME – PRINT
UNRESTRICTED DISCLOSURE OF ALL INFORMATION THAT I HAVE ENTERED WITHIN MY APPLICATION FOR MEMBERSHIP AND ANY OTHER INFORMATION OBTAINED DURING ANY INVESTIGATION OF ME PURSUANT TO MY APPLICATION BEING PRESENTED TO THE SOUTH MEDIA FIRE CO. #1, GENERAL MEMBERSHIP. I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT SUCH DISCLOSURE IS NECESSARY AND ESSENTIAL TO PERMIT THE VOTING MEMBERSHIP TO RENDER AN INFORMED DECISION AS TO MY QUALIFICATIONS AND CHARACTER FOR MEMBERSHIP IN THE SOUTH MEDIA FIRE COMPANY NO. 1
DATE ______
______
APPLICANT NAME - PRINT APPLICANT NAME - SIGNATURE
*************************************************************************
SUPPLEMENT – CADET AND JUNIOR APPLICANT
TO BE SIGNED BY PARENT &/OR GUARDIAN AT INTERVIEW ______
I, ______PARENT
&/OR
GUARDIAN OF, ______
(CIRCLE APPROPRIATE TITLE ABOVE )
APPROVE AND ALLOW FULL DISCLOSURE AS OUTLINED ABOVE.
South Media Fire Company #1 - STATION 51
535 - Washington Street - Media, Pennsylvania 19063
BACKGROUND CHECK
APPLICANT TO COMPLETE FORM DOWN TO - “POLICE DEPT. REPRESENTATIVE”
PRINT ALL INFORMATION WITH THE EXCEPTION WHERE SIGNATURE IS REQUIRED
NAME - ______
LAST FIRST MIDDLE
ADDRESS - ______
NUMBER & STREET CITY STATE ZIP
PHONE - ______
HOME WORK CELL
DATE OF BIRTH - ______S.S. #- ______BLOOD TYPE- ____
DRIVERS LICENSE # - ______CLASS: ______
DRIVING RESTRICTIONS? YES ___ NO ___ - IF YES EXPLAIN ON SEPARATE PAGE
U.S. CITIZEN: YES __ NO __ OCCUPATION ______
EMPLOYER: ______
ADDRESS: ______
NUMBER & STREET CITY STATE ZIP
HAVE YOU EVER BEE ARRESTED? YES ____ NO ____ - IF YES EXPLAIN ON SEPARATE PAGE
FINGERPRINTS REQUIRED – TO BE DONE AT NETHER PROVIDENCE POLICE DEPARTMENT
I CERTIFY THAT ALL STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
______
NAME – SIGNATURE NAME – PRINT
**************************************************************************************
POLICE DEPARTMENT REPRESENTATIVE:
HAVE YOU UNCOVERED ANY NEGATIVE INFORMATION THAT WOULD HAVE YOU RECOMMEND THAT THIS APPLICANT NOT BE CONSIDERED FOR MEMBERSHIP IN OUR
FIRE COMPANY ? YES ____ NO ____ QUESTIONABLE - ______
______ OFFICER – SIGNATURE OFFICER – PRINT