| First Name:
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| Last Name:
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| Street Address:
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| Apartment/Unit #:
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| City:
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| State:
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| Zip Code:
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| Social Security Number:
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| Birth Date:
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| Age:
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| Email Address:
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| Phone Number:
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| Have you ever been arrested: |
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No
Yes
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| If you have been arrested, please provide details:
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| Were you ever convicted of a felony: |
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No
Yes
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| If you have of a convicted of a felony, please provide details:
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| Do you have a drivers license: |
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No
Yes
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| What is your drivers license number:
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| Have you had any traffic violations: |
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No
Yes
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| If you have any traffic violations, please provide details:
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| Do you have any physical disabilities: |
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No
Yes
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| If you have any physical disabilities, please explain:
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| Are you now, or have you been a member of another fire company: |
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No
Yes
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| If you have you been a member of another fire company, please provide start date:
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| Please provide end date:
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| Reason for leaving the fire company:
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| Why do you want to be a member of Edgmont Township Fire Company #1:
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| Do you have training in any of the following: Fire, EMS, Fire Police or EVOC? If yes, did you complete? When? (please attach certifications with this application):
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| Training Certifications Upload:
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| Education / Employment |
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| Did you graduate from High School: |
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No
Yes
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| Did you graduate from college: |
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No
Yes
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| What year(s) did you graduate from H.S./College:
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| Who are you employed by:
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| Work Phone Number:
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| Job Title:
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| Are you a Military Veteran, Reservist, or Active Duty: |
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No
Yes
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| If YES, which Branch:
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| Clearance Information |
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| Do you have your PA State Police Criminal background clearance: |
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No
yes
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| Do you have your PA Child Abuse History clearance: |
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No
Yes
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| If you have been a PA resident for less than 10 years, you will need additional clearance: FBI Criminal Background Check with Fingerprinting. If you have current clearance, please attach (if you have lived in PA l0 years or longer move to next question): |
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No
Yes
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| The above referenced clearances must be renewed every 36 months. If your clearances are older than 36 months, you must renew them. (please attach current clearances):
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| Visit the websites below to obtain or renew your clearances |
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| PA Child Abuse History Clearance - https://www.compass.state.pa.us/cwis/public/home |
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| PA Criminal Background Check - https://epatch.state.pa.us/Home.jsp |
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| FBI Criminal Background Check - https://www.edo.cjis.gov/#/ (fee required) |
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| References |
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| Reference #1 Name:
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| Reference #1 Email Address:
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| Reference #1 Phone Number:
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| Reference #2 Name:
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| Reference #2 Email Address:
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| Reference #2 Phone Number:
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| Disclaimer and Signature |
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| I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application may result in my removal from the company. |
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| If you are under 18 years of age you must have a parent or guardian sign below |
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| Electronic Signature of Applicant:
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| Date:
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03/14/2025 0950 |
