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2. Application for Membership
4. Name:*
5. Date of Birth:*
7. Address:*
9. City*
10. Zip*
12. Home Phone:*
13. Cell Phone: *
15. Email Address*
17. Employer: *
18. Occupation:*
20. Employer Address:*
22. Employer City*
23. Employer Zip Code*
25. Do you have any existing medical conditions that will hinder your ability to perform the duties required of you?*

    1. Yes
    2. No
27. If yes, please explain:*
29. Will your place of employment allow you to leave work for emergency responses?*

    1. Yes
    2. No
31. Will you be able to attend department meetings and drills regularly*

    1. Yes
    2. No
33. Are you willing to respond to all calls, any time day or night when possible?

    1. Yes
    2. No
35. Are you willing to participate in all efforts sponsored or benefiting the department?*

    1. Yes
    2. No
37. Please list any training or certifications you currently have:*
39. By signing this application i am agreeing to adhere to the rules and regulations of this department. I understand that as a member i am required to respond to as many calls, meetings, and training drills as possible. I also understand that by not meeting the minimum standard set forth by the Department, I am subject to reduction in status or termination, I also understand and agree that if i am found in violation of any State or Federal Law or Department rule that disciplinary action shall be taken and membership status could be revoked.
41. Signature: *
42. Date: *
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field