Revloc Volunteer Fire Department Join Our Crew!

MONTHLY CALLS
	2020	2021
Dec 19	4	0
Jan	2	0
Feb	3	0
Mar	1	0
Apr	2	0
May	2	0
Jun	4	0
Jul	2	0
Aug	8	0
Sept	0	0
Oct	0	0
Nov	0	0
YTD	24	0
The RVFC Fiscal Year begins Dec 1 and ends Nov 30.

MEMBERSHIP APPLICATION

First Name: MI: Last Name: Email Address: Phone Number: () -

Street Address (Incl. Apt): City: State: Zip Code: - US Citizen?:

Driver's License #: State Issued: Expiration Date: / / Birthplace: Date of Birth: / /

List any experience you may have (Must be verifiable):

Have you ever been convicted of a crime?:

Please list 3 references known for at least 3 years (Excluding family):
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() -
() -

What Position are you applying for? (Select all that apply)

What is your availability?

Do you have a restriction due to a physical impairment, condition or disability?:

	By electronically submitting this membership application, I authorize the Revloc Volunteer Fire Company, it's Appointed Representatives and Line Officers to investigate my background and driving record as necessary to protect the best interests of the Revloc Volunteer Fire Company, its members and the community they serve.		

	I further authorize the Revloc Volunteer Fire Company, Appointed Representatives and Line Officers to verify all information to the fullest extent required in accordance with their bylaws. All information obtained upon verification can and may be used in making a final determination in the outcome of my membership application.

	Any information withheld from the Revloc Volunteer Fire Company upon submitting this application may result in withdrawal of my application and immediate denial for the determination. I agree to disclose any and all information about my status as it stands with my Criminal, Child Abuse & Department of Public Welfare Records as deemed necessary by the Commonwealth of Pennsylvania. I also agree to obtain, on my own, a copy of a Pennsylvania State Police (PSP) Criminal Background Check and a copy of a Department of Public Welfare Child Abuse Clearance. I understand these will not be reimbursed by the department should I be charged to obtain them, nor will they guarantee acceptance of my application."

I have read and agree with the disclosure.