| Your Full Name: |
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| Your Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Telephone (Day): |
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| Telephone (Cell, Work, Pager): |
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| Email Address: |
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| N.Y. State Driver Licence Number: |
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| Do You Own A Vehicle: |
YES
NO
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| Do You Have Military Service (If No, Skip Down 3 Questions): |
YES
NO
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| Branch: |
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| Type of Discharge: |
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| Reserve Status (If N/A, Skip Down 2 Questions): |
N/A
ACTIVE
INACTIVE
DISCHARGED
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| Are You Meeting Your Reserve Status Requirement?: |
YES
NO
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| Current Employer: |
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| Current Employer Address: |
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| Current Employer City: |
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| Current Employer State: |
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| Current Employer Zip Code: |
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| Education (Explain Level Completed, High School, College, Masters, ect.): |
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| Have You Ever Been CONVICTED of A Crime, Including Misdemeanors and Traffic Violations? (Explain): |
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| If You Do Not Live In The Fire District, Explain Ability To Respond To Calls: |
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| Do You Have Any Previous Fire Company or First Aid Experience? (Not Required To Join): |
YES
NO
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| If Yes, Explain What Training or Certifications You Have: |
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| Personal References (Excluding Relatives): |
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| Explain Your Reasons For Desiring Membership in Harris Hill Volunteer Fire Company: |
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| How Long Have You Lived at Your Present Address?: |
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| List Prior Addresses For Last 5 Years: |
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| With Whom Do You Live With?: |
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| I Hereby Agree to Abide By The Constitution, By Laws, and Other Rules of The Harris Hill Fire Company If Elected: |
YES
NO
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| I Hereby Agree That The Facts Set Forth In The Above Application Are True And Complete To The Best of My Knowledge: |
YES
NO
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