I desire to become a member of the Ridge Fire Company. (Please Print)

Name:_________________________ Age:____

Address:_______________________________ Home Phone Number:(____)____-_______

City:_________________ State:___ Zip:________-____(Plus 4 if known)

State of Birth:______ Date of Birth:___/___/_____ Social Security#:_____-____-_______

Drivers License Number and State:______________ _____

Occupation:___________________________ Work Phone Number:(____)____-_______

Do you wish to be; Active:____ Social:____ Fire Police:____

Have you had previous Fire/Rescue/Ambulance service or training? Yes:____ No:____

If yes to above please list previous department(s), training, and certificate(s). Use separate page if needed.           ________________________________________________________________

Do you have any medical and/or physical conditions that would affect your performance as a fire fighter? Yes:____ No:____ If yes please describe.________________________________________

List other organizations or references:_________________________________________

All applicants under the age of 18 years old shall obtain signed permission from parent or guardian. Working papers MUST be obtained before application will be considered.

            Parent/Guardian:_____________________ Date:___/___/_____

Have you ever been convicted of a felony? Yes:____ No:____ If YES explain.

            __________________________________________________________________

The information on this application is true to the best of my knowledge. False information is grounds for rejection or dismissal from company.

Signature:_____________________________ Date:___/___/_____

Fire Company Sponsor:______________________________ Date:___/___/_____

Application Fee of $3.00 paid. Yes:____ No:____ {Under age 18 free}

  I authorize Ridge Fire Company No.1 to contact any and all my references. I understand that a criminal record check may be conducted through the state and/or local enforcement agencies and I authorize such agencies to release records concerning my criminal background and history. I understand that the discovery of any misrepresentation or omission may be a cause for denial of membership to Ridge Fire Co.

Signature:___________________________________

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Office Use Only:

Investigation Committee Report

__________________________________ Accept:_____ Reject:_____

__________________________________ Accept:_____ Reject:_____

__________________________________ Accept:_____ Reject:_____

Accepted:_____ Rejected:_____ From membership Date:___/___/_____

Company Secretary:______________________________ Date:___/___/_____