Volunteer

Contact Information

Title

First Name

Middle Name

Last Name

Suffix

Address *

Address

Primary Phone Number *

Secondary Phone Number

Personal Information

Date of Birth *

Current Age

Occupation

Drivers License Number

Licensing State

Expiration

Are you a resident of Lower Paxton Township? *

Yes

Have you lived outside of Pennsylvania in the past 10 years? (PA requires a FBI background check for those that have not lived in PA continuously over the past 10 years.) *

Yes

Are you a U.S. citizen or do you hold a valid work visa? *

Yes

Do you currently have any medical conditions that would prevent you from performing any firefighting duties?

Yes, please provide detailsYes, please provide details

Have you ever been convicted or plead guilty to a felony offense? *

If yes, please provide details including all offenses and dates.If yes, please provide details including all offenses and dates.

References

Reference # 1

Phone Number (Mobile Preferred)

Reference #2

Phone Number (Mobile Preferred)

Reference #3

Phone Number (Mobile Preferred)

ACKNOWLEDGEMENT
In the course of my application for membership in the Colonial Park Fire Company #1, the officers and members of the company may desire to make certain inquires as to my background, character, and experience. It is in my interest to permit such investigations to take place by the officers: and therefore, in consideration of my desire to have all material considered, I hereby authorize the Colonial Park Fire Company #1, its members and officers, and the Lower Paxton Township Police Department, to make such inquiries as they deem appropriate. This includes, but is not limited to, any individual or group, institution, current or former employer, or emergency service agency. It is understood that I shall make no claim against the persons furnishing information and shall make no claim against any of the afore mentioned sources of information, including the Colonial Park Fire Company #1 and the Lower Paxton Township Police Department, for providing or reasonably using any or all information. Also, to the best of my knowledge, all statements and answers which I have given are true, correct, and accurate. I further understand that any misrepresentation or omission of facts may result in nullification of this application and/or subsequent membership based on its contents. I solemnly swear that all information given in this application for membership to Colonial Park Fire Company is accurate to the best of my knowledge. I also understand that if it is proven that I intentionally falsified the information provided, I may be rejected for membership without a chance for reapplication. If proof of falsification occurs after being accepted into membership, I also understand that the falsification may be grounds for my expulsion from the Colonial Park Fire Company. Finally, I swear to uphold all fire company By-Laws and Standard Operating Procedures and to treat fire company property with the greatest care. By dating and signing this application, I attest and swear to the following: “I have never been convicted of an offense that constitutes the crime of “arson and related offenses” under 18 Pa. C.S 3301 or any similar offense under any Federal or State law. I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that if I knowingly make any false statement herein, I am subject to penalties prescribed by law.

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