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Eeaman. !Jeace fliJte 0m~any

5-7 Hershey Avenue .. POBox 98 Paradise, PA 17562

APPLICATION FOR MEMBERSHIP

Nrume
Address Home Phone #

Date of Birth
City

1__

1__ State

Current Age Zi p SS# __ __ _

L-)

CeU Phone # ('--_~) Phone #

__

__

Current Employer . References References

L-)__ __

Yr's Employed
)

_
_ _

Phone # ('Phone # ('--

Are you or have you ever been a member of another Fire Company: Name of Fire Companay Reason for Leaving _

If so, how long? Phone # ('-) __ _

_ _

Drivers License # Any U.S. Military Service?

Ever suspended?

if so, why

_ _

Presently a member of Nat'I Guard or Reserve?

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Have you ever been convicted of any criminal charges or have a court record? If yes explain
.AIe

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you currently under a Physicians care? ----------------

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if so, for what reason?

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Family Doctor

Medications

---------------Phone # C'--_-'

Emergency Contact Person/relationship Active Member Sponsoring Sponsors Signature

-----------------------------------Date ------" , Fire Police

Au:dlary

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This application is for

FIrefighter __

Jr. Firefighter

I, Paradise to make attempt in order

Solenmly Swear that I will abide by the Constitution and By-Laws of [ii\:" Leaman Place Fire Company (P&LP Fe) and will to the best of my ability, support and \\0,0_ the P&LP Fe a better organization. By singing this application it is understood that I wi II to reach all training goals and requirements set by P&LP Fe and by the state of Pennsylv ari~ to fulfill my obligation. Authorize investigation of all statement contained in this appl icarion. that misrepresentation or omission of facts called for is cause for rejection of this

L understand

application.

Signature of Applicant

Date

! ---

If applicant is under the age of Eighteen (18) parent or legal guardian must sign. Signature of Parent/Guardian Any other information ----------------------Date I -----!

you wish to offer/include

please write below

Date approved for Trial Membership

__

1__

1__

final Member Date