Wysox Volunteer Fire Company - Membership Application
P,O, Box 2 | Wysox, PA 18854 | 570-265-8866
Application for Membership
Type of Membership Applying for: *
Legal Name: *
First and last name
Street Address: *
Date Of Birth: *
Social Security Number:
Drivers License #: *
Email Address
Phone Number: Home &/or Cell *
Employer: *
Occupation: *
Employer's Address *
Employer's Phone #: *
Reference: (Not Former Employers or Relatives) Name & Number Required *
Reference: (Not Former Employers or Relatives) Name & Number Required *
Reference: (Not Former Employers or Relatives) Name & Number Required *
Fire Company Sponsor: *
I hereby apply for membership with the Wysox Volunteer Fire Company and, if accepted, will follow all directives and orders issued in accordance with the By-Laws of the Company. I consent to the release of information about my ability or background by employers, schools, Law Enforcement Agencies, and other individuals and organizations, to members of the Wysox Volunteer Fire Company. My signature indicates my acceptance and understanding that any misrepresentation of face on this application will disqualify me from membership. I further understand that my application may be rejected for any reason by the membership of the Wysox Volunteer Fire Company at the time of initial membership vote or at the time my 6 month probationary period is over.

Annual Membership Dues ($5.00 and must accompany application), will not be returned if the Membership is rejected. I further understand that I must make this application in person at a Regular Monthly Meeting of the Wysox Volunteer Fire Company, held on the 2nd Monday of each Month at 7:00PM.
Signed: *
Date: *
MM
/
DD
/
YYYY
Do you have any previous Firefighting and/or Rescue experience? *
If YES, please fill out the information below. Please be sure to include copies of any verifiable Training Certifications you may have received when turning in your application.
Fire Company / Department:
Address of above Company / Department:
Contact Name:
Contact Number:
Fire Company / Department:
Address of above Company / Department:
Contact Name:
Contact Number:
Please list all verifiable Training Certifications you have:
If this application is approved and you are voted into membership, you will be eligible to receive Group Medical and Life Insurance Benefits. Please list below the person you wish to identify as Beneficiary to these benefits.
Name: *
Address: *
Submit
Never submit passwords through Google Forms.
This form was created inside of Wysox Fire. Report Abuse