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Fire Department Application

Phone

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Application for Department Membership

Name

First Last

Date

Address

DOB

City, State & Zip

Phone

Hose Company Joining

Email

Are you over the age of 18?

Yes

No

I hereby agree to take an active part in all fire fighting activities, attend the first fire school class and special demonstrations pertaining to fire fighting when available and to obey the orders of my superior officers at all times. I also agree to abide by the Constitution and By-laws of the DuBois Volunteer Fire Department, DuBois, PA and the DuBois Volunteer Firemen's Relief Association, DuBois, PA.

Parent or Guardian Signature (if under age 18)

Applicant Signature

Application for Relief "Death Benefits" Membership

I desire to become an eligible member for the "Death Benefit" of the DuBois Volunteer Fireman's Relief Association. My membership being based upon being a member of the above named company. I hereby designate as my beneficiary to whom such death benefit shall be payable:

Name

First Last

Relationship

Address

City, State & Zip

Parent or Guardian Signature (if under age 18)

Applicant Signature

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