THE RENOVO FIRE DEPARTMENT
230 11TH STREET, RENOVO, PA 17764
570-923-0210

APPLICATION FOR MEMBERSHIP

Name: ____________________________________________________________________

Phone: ____________________________________________________________________

Address:___________________________________________________________________
 
DOB: ______________________________________________________________________

SSN: ______________________________________________________________________

Age:_______________________________________________________________________

DL#: ______________________________________________________________________

CPR Certification: ( ) YES ( ) NO If yes, Expiration Date:

__________________________________________________________________________
 
Have you ever been convicted of a crime: ( ) YES ( ) NO If yes, please explain:

__________________________________________________________________________

Have you ever been a member of another fire department? ( ) YES ( ) NO If yes, which department?

___________________________________________________________________________

Do you have any physical impairments that would prevent you from performing duties of this department? ( ) YES ( ) NO If yes, please explain:

___________________________________________________________________________

Please list all current certificates that you possess:
 
___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

I give my consent for a background and criminal history check. Application fee - $1.00 __________________________________________________________________________

Applicant’s signature: _________________________________________________________

Parent or Guardian if applicant under 18:__________________________________________

Official Use Only
 
( ) Declined
( ) Active with Fire-fighting Privileges
( ) Accepted Date:_____________
( ) Active with Non Fire-fighting Privileges
( ) Probationary Period Ending Date:
( ) Social Member ______________________________
( ) Fire Police
( ) QRS

_______________________________________________________________
Board of Director’s Chairman & Date