Application for Junior Membership

I respectfully apply for membership in the Shelton Volunteer Fire Co. #4 Inc. and hereby promise and agree that if admitted to membership, I will conform to the constitution and bylaws of the company and that I will perform to the best of my abilities, all of the duties that may be required of me. I will also be personally responsible for all equipment and property issued to me.

Personal Information

First Name: Last Name: Middle Initial: Date of Birth / /

Address: City: State: Zip Code:

Phone Number ( ) - Best time to contact you:

Email:

Contact Preference:

Education

High School

Name: Location (City, St ) Years attended:

Employment

Current Employer:

Address: City: State: Zip Code:

Supervisor: Job Title:

Duties:

Emergency Service Experience

Fire

Department Name: Years of Service

EMS

Department Name: Years of Service

Have you ever been convicted of a felony or misdemeanor?

Do you have any medical problems which could limit your effectiveness as a firefighter?

Please tell us why you want to become a junior member of Pine Rock Park Co. 4

I hereby certify that all statements in this application are true and complete to the best of my knowledge, and I understand that any answers or statements the I have submitted found to be false will be grounds for immediate dismissal from the company if this application is accepted.

I agree to the above statement