Marshall Township Volunteer Fire Department

PO Box 216, Warrendale, PA 15086

Station #1: 270 Northgate Drive, 724-935-1230

Station #2: 465 Knob Road, 724-935-1020

Fax: 724-934-5996

Application For Membership

(Please Print)

Name:___________________________________ Date:______________________

Address:________________________________________________________________

City:___________________ State:___________ Zip Code:_____________

Home Phone:_______________________ Work Phone:________________________

Employer:_______________________________________________________________

Address:________________________________________________________________

City:___________________ State:___________ Zip Code:_____________

School: (if student)_______________________ Work permit #:__________________

Social Security Number:_______________________ Date of Birth:______________

Driver’s License Number:_______________________ Expiration Date:___________

Please list and supply training records of past experiences. (Examples: fire fighting, rescue and/or other) Please use additional paper if needed:

________________________________________________________________________

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Name of Spouse or Guardian:________________________________________________

Insurance Beneficiary:_____________________________________________________

Beneficiary Address:_______________________________________________________

Family Doctor:________________________________ Phone:____________________

In case of injury who do we notify:___________________________________________

Relationship:_______________________ Phone:______________________________

Blood Type:__________________

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We consider applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, marital status, or any other legally protected status. Applicants requiring accommodation in the application process should contact The Marshall Township Volunteer Fire Department (MTVFD).

Position applying for:

Active Company Member Active Brigade Member

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How did you learn about us: _______Advertisement ________Friend ________Relative

Walk-in Other_______________________________________________

Community Events

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Have you been convicted of a felony or misdemeanor: ________Yes ________No

If yes, please explain:______________________________________________________

_______________________________________________________________________

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Applicants must complete the standard MTVFD application form, have it cosigned by an active member, and present it to the President of the MTVFD along with a fee of ten dollars. We will return the application fee to any applicant who is refused membership.

MTVFD Representative:_______________________________ Date:___________

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All Applicants:

I certify that all answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for membership as may be necessary in arriving at an membership decision. I also authorize a complete background investigation including a criminal check.

In the event of membership, I understand that false or misleading information given in my application or interview(s) may result in discharge.

I hereby release the organization and all of its members from responsibility for any injury that I incur providing service as a member of the volunteer fire company or participating in any of its activities. I certify that the applicant has adequate medical and life insurance coverage separate from any that may be provided by the fire department.

I understand, that I am required to abide by all published and inherent rules, by-laws and regulations of MTVFD.

Signature of Applicant:______________________________ Date:________________

For Applicants Between The Age of 16 and 18:

You must be at least 16 years of age to apply for membership. Any applicant under 18 years of age must provide a work permit made out to MTVFD.

A legal guardian must sign the following release for applicants under 18 years of age.

As legal guardian of the above applicant, I hereby consent to his or her membership in this organization and do hereby release the organization and all of its members from responsibility for any injury that he or she may incur while providing service as a member of the volunteer fire company or participating in any of its activities

Name of Guardian ____________________________ Phone:___________________

Signature of Guardian:______________________________ Date: _________________

State any Additional information you feel may be helpful to us in considering your

application: ______________________________________________________________

________________________________________________________________________

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(For office use only)

Application and fee received on:_______________ Received By:__________________

Investigation by:____________________________ Date Completed:_______________

Date Interviewed by Board of Directors:_____________ Approved Disapproved

Remarks:________________________________________________________________

Date Provisional Member Sworn In:_________________________

Sworn in by:_____________________________ Title:___________________________

Dated Voted on at Business Meeting:______________________

Number of votes: Yes_______ No:________ Total Voting:__________

Member Accepted By Body: Yes:______ No:________

Status of Member as Voted upon:_____________________________________________

Member Changed Status From:________________ to ________________ Date_______

Departure Date:______________________

Remarks:________________________________________________________________

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