LAWRENCE TOWNSHIP FIRE COMPANY #1
425 MILL ROAD CLEARFIELD, PA. 16830 CLEARFIELD COUNTY STATION 5 PHONE 7658683
APPLICATION FOR MEMBERSHIP
I HEREBY PRESENT MYSELF AS A CANDIDATE FOR MEMBERSHIP AND AGREE, IF ELECTED, TO BE BOUND BY THE CONSTITUTION AND BY-LAWS AND WILL WORK TO THE BEST OF MY ABILITY TO SUPPORT THE COMPANY IN ALL ITS UNDERTAKINGS AND PURPOSES AND FAITHFULLY CARRY OUT ALL DUTIES ASSIGNED TO ME.
DATE_____________ PHONE___________________S.S. NUMBER_____________________________________
NAME AND ADDRESS __________________________________________________________________________
BIRTHDATE_______________________OCCUPATION_______________________________________________
EMPLOYER AND ADDRESS_____________________________________________________________________
BENEFICIARY, RELATIONSHIP AND ADDRESS___________________________________________________
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LIST ANY PHYSICAL AND/OR MENTAL IMPAIRMENTS___________________________________________
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LIST TWO REFERENCES WITH PHONE NUMBERS________________________________________________
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WERE YOU EVER DENIED MEMBERSHIP OF OR DISMISSED FROM ANY FIRE COMPANY OR EMERGENCY SERVICE?______ IF YES, LIST ORGANIZATION ANDADDRESS________________________
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SIGNATURE OF APPLICANT____________________________________________________________________
THIS APPLICATION MUST BE ACCOMPNIED BY A $10.00 NON RETURNABLE APPLICATION FEE
***IF UNDER THE AGE OF 21, PARENT OR GUARDIAN MUST SIGN***
I GIVE MY CONSENT TO MY SON/DAUGHTER/WARD TO BECOME A MEMBER OF LAWRENCE TOWNSHIP VOL. FIRE COMPANY NO. 1
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SPONSORED BY______________________________________AND_____________________________________
COMPANY USE ONLY ---------------------------------------------------------------------------------------------------------------
DISPOSTITION: ELECTED ( ) REJECTED ( ) DATE_________________________
CERTIFICATION OF DISPOSITION________________________________________________________
1ST READING______________________ 2ND READING_______________________