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Application for Membership


La Mott Fire Company
7600 Penrose Avenue
Elkins Park, PA 19027


Required   Indicates Required Field
Name: Required
Best Contact Phone: Required
Address:
E-mail Address: Required
Are you at least 18 years old?: Required
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): Required
Are you currently a member of any other fire / EMS companies: Required
If Yes, please list all :
Are you available for training Monday and/or Tuesday nights: Required
Have you ever been convicted of a crime: Required
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: Required
Reference #1 Address:
Reference #1 Best Contact Phone: Required
Reference #1 - Relationship: Required
Reference #2
Reference #2 Name: Required
Reference #2 Address:
Reference #2 Best Contact Phone: Required
Reference #2 - Relationship: Required
Reference #3
Reference #3 Name: Required
Reference #3 Address:
Reference #3 Best Contact Phone: Required
Reference #3 - Relationship: Required
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: Required
Submitted on: 08/11/2022 0352


All information in this application will be considered confidential.
It will not be shared by the La Mott Fire Company





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LaMott Fire Company
PO Box 8851
Elkins Park, PA 19027-0851
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