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Whitehall Volunteer Fire Company
Application for Membership
Membership Preference *
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First Name *
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Last Name *
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Social Security Number *
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Current Street Address *
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City *
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State *
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Zip Code *
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Previous Street Address
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Previous City
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Previous State
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Previous Zip Code
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Home Phone *
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Email Address *
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Date of Birth *
DD/MM/YYYY
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Gender *
Employer
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Position
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Employer's Street Address
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Employer's City
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Employer's State
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Employer's Zip Code
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Work Phone
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Emergency Contact 1 *
Primary Contact
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Relationship to Primary Contact *
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Phone Number for Primary Contact *
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Emergency Contact 2 *
Secondary Contact
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Relationship to Secondary Contact *
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Phone for Secondary Contact *
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Height
(optional)
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Weight
(optional)
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Blood Type
(optional)
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Organ Donor
(optional)
Date of Last Physical (mo/yr)
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Family Physician
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Family Physician's Phone
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Medication(s)
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Comments on Medications
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Allergies
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Driver's License Number
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Class
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Restrictions
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Expires (mo/yr)
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Vehicle Make & Model
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Vehicle Year
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License Plate Number
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License State
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Have you ever been refused membership in an emergency service organization? *
Have you ever been discharged from an emergency organization? *
Have you ever been convicted of, or plead to a misdemeanor or felony? *
The Whitehall Volunteer Fire Comany Inc. By-Laws Article 3 Section 1, forbids persons convicted of a felony attainment of membership.
If 'Yes', please explain
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Reference 1 *
Person not related to you that we may contact for a personal reference.
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Reference 1's Phone *
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Reference 2 *
Person not related to you that we may contact for a personal reference.
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Reference 2's Phone *
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Reference 3 *
Person not related to you that we may contact for a personal reference.
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Reference 3's Phone *
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Organization 1 Name
List any fire, ambulance or police organizations to which to have belonged.
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Organization 1 Phone
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Organization 1 Officer in Charge
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Organization 2 Name
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Organization 2 Phone
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Organization 2 Officer in Charge
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List any emergency service training
(fire, ambulance, police, etc.) and any other skills you would consider to be beneficial to our organization.
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