Application for Membership - Wagontown Fire Company

Indicates Required Field

Application Fee is $15.00. Due at the time of meeting with Investigation Committee.

Application Info

Date/Time

10/17/2026 1726

Type of Application Required

New Reinstatement from Inactive Membership

Check Membership Applying for Required

Junior (under 18) Active (age 18 & up) General

Personal Information

First Name Required

Middle Initial Required

Last Name

Other Names (Alias, Maiden, etc.)

Date of Birth Required

Address

City

State

Zip

Telephone

E-mail Address Required

Marital Status Required

Single Married Widowed Divorced

Additional Information

Do you have a Driver's License? Required

Yes No

Number

Class

State Issued

Emergency Contact

Contact Name Required

Contact Relationship Required

Contact Phone Required

References

Reference 1

Phone Number 1

Reference 2

Phone Number 2

Reference 3

Phone Number 3

Background Information

Have you been convicted or plead guilty to a misdemeanor/felony? Required

Yes No

If yes, list all offenses and state date, place and action taken

Training (Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.)

Please Include all training Including (Training Level) (MFRI / MIEMSS I.D. Number) (Completed or Expiration Date)

Please add copies of your certifications here

Add files...

Employment

Are you currently employed Required

Yes No

Place of Employment

ADDITIONAL RESCUE SQUAD/EMS/ALS/FIRE INFORMATION

Are you a member of another Rescue Squad, EMS,ALS or Fire Department? Required

Yes No

Have you ever been a member of another RescueSquad, EMS, ALS or Fire Department? Required

Yes No

If yes, explain

Attach a list of all Rescue Squad, EMS,ALS or Fire Department organizations to which you were either a paid and/or volunteer member. Include date (from/to), and any offices held

Background Check Statement

I grant the Investigation Committee permission to perform investigative interviews, including background checks to obtain membership. Any findings may be made public at the monthly meeting and may have direct impact on my application for membership. Required

Yes No