Membership Application - North Braddock Fire Department

Application

First Name

Last Name

Street Address

City

State

Zip

Phone

Drivers License Number

Date of Birth

Occupation

May We Contact You Employer. If Yes, Name & Number

Highest Grade Completed In School

College/Trade School

Were you ever a member of any other emergency response organization?

Yes

Reason for leaving (if applicable)

May we contact your former Chief or President? (Include Name & Number

Past Training (FIRE or EMS):

Have you ever been convicted of a crime? ( Yes / No ) If yes, Please Explain:

Have you ever been addicted to drugs or alcohol? ( Yes / No ) If yes, Please Explain:

Have you had any disabling illness or injury within the past five years? ( Yes / No ) If yes, Please Explain:

Why do you want to become a member of the department?

List three (3) references (NOT RELATED) name, address, and phone number

By fully completing and submitting this application for membership, you are permitting North Braddock Volunteer Fire Department, Inc. to conduct a background investigation, including, but not limited to, a complete criminal search of their records to ensure that all information above is factual. Any discrepencies in the applocation may result in the disqualification of the opportunity to join the department. Proof of training (certificates) will be required.

Applicants accepted by the Department shall serve one (1) year probation. I have read the above statement and have completed the application truthfully and factually, and to the best of my ability.

Signature of applicant

Clear

Signature of Parent/Guardian

Clear

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