Membership Application

Your Personal Information

Your Name(Required)

First Last

Your Email Address

Enter Email Confirm Email

Date Of Birth(Required)

SSN

Optional

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone(Required)

Best Time To Call You

When is the best time for us to reach you via telephone?

Position You're Applying For

Position You're Applying For(Required)

Firefighter

Junior Firefighter

Fire Police

Auxiliary

Support Staff

Other

Background

Your Current Employer

Please list your current employer and supervisor

Employer

Address

Phone

Supervisor

References

Please list three references (not related)

Name

Address

Phone

Years Known

References

Name

Address

Phone

Years Known

Name

Address

Phone

Years Known

Tell Us About Yourself

OPTIONAL: Upload Your Firefighter Resume

Accepted file types: pdf, doc, docx, Max. file size: 100 MB.

Have you ever been convicted of a misdemeanor or felony in the past seven years, which has not been annulled or expunged or sealed by the court?

READ THIS INTRODUCTION CAREFULLY BEFORE ANSWERING THE QUESTION IN THIS AREA. The Civil Rights Act of 1964 prohibits discrimination because of race, color, religion, sex or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, or disability. Because this is a volunteer organization, positions become available in the administrative portion of the organization; therefore the following information IS required by this organization. Conviction of a crime will not be an absolute bar to membership

Answer(Required)

Criminal History Disclosure

You have selected yes, please describe in full in this space

Consent(Required)

The facts set forth in my application for membership are true and complete. I understand that if I am accepted as a member, any false statement on this application may result in my expulsion from the organization. I hereby give permission to contact my employer and references listed above. I agree to a background and social media check. I also agree to conform to the rules and guidelines of the Brecknock Township Fire Company #1.

I Agree

Your Personal Information

Position You're Applying For

Background

Have you ever been convicted of a misdemeanor or felony in the past seven years, which has not been annulled or expunged or sealed by the court?

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Brecknock Township Fire Company

1153 Kurtz Mill Road

Mohnton, PA 19540

610-777-9575