MACEDON
CENTER FIRE DEPARTMENT
APPLICATION FOR MEMBERSHIP
All sections of this application must be
filled out to be considered for membership.
Use the back of this application for
additional space if needed.
Attach copies of any firefighting
certificates and both sides of your drivers license.
[ ] Social
Membership
Name _______________________________________ Age _____ Date of Birth ___/___/___
Street _______________________________________ Town ______________ Zip _________
Phone _________________ Drivers License No. ___________________ Class ______
Do you have any medical conditions
that would restrict firefighting activities? ______ If so, please describe
_________________________________________________________________________
Employer ________________________________ Title
____________________________
Address _________________________________ Phone
__________________________
_________________________________ Work
Hours ______________________
Would your employer have a problem if you were late to work
due to a fire emergency? __________
Do you have any past experience in firefighting? _________
Fire Department _____________________________________ Dates _____________________
Please list any other departments & dates
_______________________________________________
Please list any fire related classes/training you have taken
__________________________________
Please list any past leadership positions you have held in
the fire service ______________________
Have you ever been convicted of any crime (felony or misdemeanor)?
_________
If so, please describe
_______________________________________________________________
Sign
here to authorize the state mandatory background check for arson ®______________________________________
The
information stated above is true to the best of my knowledge. I understand that if the information
supplied above is knowingly false, I may be disqualified for membership.
______________________________________________ _______________
11/00 Sign Here Date