Application for Regular 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
    Name:        Date of Birth: 
    Address:    City:    Zip Code:
    Phone Number:()-    Spouse/Parent (if under 18):
    Emergency Contact: Phone Number of Emergency Contact:()-

Motor Vehicle Information
    Make:    Model:    Year:
    Color:    Registration Number:
    Drivers license type: Class 2 CDL Other        Expiration Date:

Education
    High School:                            Years Attended:
        Location:                Did you graduate? YesNo   Year:
    College:                            Years Attended:
        Location:                Did you graduate? YesNo   Year:
    Other:                            Years Attended:
        Location:                Did you graduate? YesNo   Year:

Did you serve in the Military? Choose One Yes No     If Yes, what branch:
                Years of Service:    Job:
                Special Training or Commendations:

Employment
    Current Employer:        Job Title:
    Address: City: State:
    Description of Duties:                                                        Supervisor:   
                                   

Emergency Services Experience: (Paid and/or volunteer)
    Fire Department:  Location: Years of service:
    EMS:  Location: Years of service
    Police:  Location: Years of service

Please list some of your hobbies, or clubs/groups you may belong to:
                                                                                                               

Convictions;(Traffic or Criminal)
    Have you ever been convicted of a felony or misdemeanor? Choose One Yes No
            If Yes, please explain:
                                               
    Have you ever been in a motor vehicle accident while driving? Choose One Yes No
            If Yes, please explain:
                                               
Have you ever a traffic summons? Choose One Yes No
            If Yes, please explain:
                                               

Do you have any medical problems which could limit your effectiveness as a firefighter? Choose One Yes No
            If Yes, please explain:
                                               

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

I agree to the above statement