Application for Membership - LaMott Fire Company

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Application for Membership

Indicates Required Field

Name:
Best Contact Phone:
Address:
E-mail Address:
Are you at least 18 years old?:
Previous Address:
Current Employer:
Position:
How many long have you been with current Employer:
Previous Employer:
Previous Position:
How many long have you been with previous Employer:
May we contact your employer(s):
Are you currently a member of any other fire / EMS companies:
If Yes, please list all :
Are you available for training Monday and/or Tuesday nights:
Have you ever been convicted of a crime:
If you have you ever been convicted of a crime please explain:

Please provide a minimum of three (3) references. These references may not include family members.


Reference #1

Reference #1 Name:
Reference #1 Address:
Reference #1 Best Contact Phone:
Reference #1 - Relationship:

Reference #2

Reference #2 Name:
Reference #2 Address:
Reference #2 Best Contact Phone:
Reference #2 - Relationship:

Reference #3

Reference #3 Name:
Reference #3 Address:
Reference #3 Best Contact Phone:
Reference #3 - Relationship:

I understand and agree that any willful misstatement made by me in the application will be sufficient cause to deny membership or for discharge from the Fire Company.

Electronic Signature of applicant:
Submitted on:		04/25/2024 2216
All information in this application will be considered confidential. It will not be shared by the La Mott Fire Company

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www.FirehouseSolutions.com	LaMott Fire Company PO Box 8851 Elkins Park, PA 19027-0851	Emergency Dial 911 Non-Emergency: 215-635-0996 Station Fax: 215-635-0958 E-mail: info@lamottfire.com