= Required

Which type of member would you like to apply?
Full Member Junior Member Associate Member

First Name

Middle Name

Last Name

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Date of Birth

Age

Social Security Number

xxx-xx-xxxx

Occupation

Employer Name

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

xxx-xxx-xxxx

Employed Since

If you have had previous Fire Company or Ambulance experience, enter it below

Name of Company

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Non-Emergency Number

xxx-xxx-xxxx

If you have had training and certifications, please enter it below

Cardiopulmonary Resuscitation
Yes No

Expiration Date

COM
Yes No

Expiration Date

Basic Life Support
Yes No

Expiration Date

Emergency Response
Yes No

Expiration Date

First Responder
Yes No

Expiration Date

Certification Number

Emergency Medical Technician
Yes No

Expiration Date

Certification Number

Introduction to Safety Training
Yes No

Expiration Date

Certification Number

Basic Vehicle Rescue
Yes No

Expiration Date

Certification Number

Emergency Vehicle Operator
Yes No

Expiration Date

Certification Number

Other Training

Expiration Date

Certification Number

Other Training

Expiration Date

Certification Number

Membership Guidelines require a criminal record check. Please visit the PA State Police website, where you can have your background check done for $10. When you receive the completed Background Check, mail or bring it to the Fire Company. If you want to drive emergency vehicles, an Emergency Vehicle Operator Course and Drivers License Check may also be required.

Have you ever been convicted of a felony or misdemeanor?
Yes No

If you have, please explain

Do you have any physical or mental disabilities which could limit your safe participation in fire company activities?
Yes No

If so, please explain

Have you had a 3D Hepatitis B vaccine?Yes No

Date

Have you had a Tetanus Booster?Yes No

Date

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References: Use Business associates, co-workers, etc. DO NOT use family members or clergy. Due to previous experience with new members, we need to check references.

First Name

Last Name

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

xxx-xxx-xxxx

Relationship

How many years?

---

First Name

Last Name

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

xxx-xxx-xxxx

Relationship

How many years?

---

First Name

Last Name

Address

City

State
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone

xxx-xxx-xxxx

Relationship

How many years?

---

Have you been recommended by a Tafton Fire Company member?
Yes No

If so, who?

---

Tafton Fire Company will not discriminate on the basis of race, color, national origin, sex, or handicap in it's activities, programs or membership.

Please Note: Applications received are read at the next fire company meeting following receipt, references are checked, and applications are voted at the following fire company meeting unless there is a problem. If a problem arises, applicant will be notified by phone or in writing. Memberships do not take effect until dues are paid for year of application.

Be Advised: You will be asked to come in for an interview.

All equipment issued to members, belongs to the Tafton Fire Company. I will take care of any property and equipment issued to me. Equipment must be returned upon request or termination to the Tafton Fire Company.

Under penalty of perjury, I certify that the above information is true. Upon being voted in as a member of the Tafton Fire Company Inc, I agree to abide by the current by-laws, rules & regulations and guidelines. (A copy of the by-laws is available upon request prior to joining.) I will obey any reasonable request issued by a superior officer.

Please type your full name, as it appears at the top of this form. This, along with the digitally recorded date, time and your IP address, will constitute your Digital Signature. If you are under 18 years of age, you must have your Parent or Guardian make an appointment to visit the Tafton Fire Company, to approve and sign your documents.

I agree to all of the terms in this document

Digital Signature (Your Full Name)