| Date Submitted:
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04/12/2026 0225 |
| What Type Membershp are you Applying For?:
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| Personal Information |
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| First Name:
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| Middle Name:
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| Last Name:
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| Date of Birth:
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| Preferred Name:
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| Sex::
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| Home Phone:
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| Cell Phone:
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| Email Address:
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| Current Address |
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Street Address:
Eg. 29 E. 5th Avenue
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City:
Eg. Collegeville, Trappe, Royersford, Perkiomen
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State:
Eg. PA, MD, DE,NJ
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| Zip Code:
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| Years at Current Address:
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| Previous Address Information |
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Previous Address :
Street Address, City, State, Zip Code
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| Years at Previous Address:
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| Driver License Information |
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| Driver's License Number:
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| Class of Drivers License:
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| State Issuing Drivers License::
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Copy of License:
Please attach a copy of your license
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| Has your driver's license ever been suspended?:
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| Have you ever been convicted of a traffic violation, misdemeanor, or a felony::
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| If Yes, indicate the date and nature of the charge, police agency, court, and disposition::
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| Employment Information |
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| Employment Status?:
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Current Occupation & Employer Information:
Include Address; phone numbers and years employed
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| Previous Employers:
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| Military Service |
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Which Branch of Military Did You Serve In?:
If yes, please check appropriate Branch
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| Military Id #:
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| Enlistment or Appointment Date to Military Service:
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| Discharge Date from Military:
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| How were You Discharged:
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| Tell us about you |
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Community Activities:
Lions Club, Scouts etc.
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| Do you Physical Limitations that would prevent you from performing Firefighting duties: |
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Yes
No
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| If Yes Explain Physical Limitations:
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| Have you ever been convicted of a crime?: |
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Yes
No
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| If you HAVE been convicted of a crime please describe the circumstances.:
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| EDUCATION |
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High School Attended:
Include Location (City/State)
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| Did you graduate or receive a GED::
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| Date graduated, or ceceived GED::
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College or University:
College or University, Location (City/State)
Dates attended, Major or Degree awarded
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| Experience |
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| Have you ever filed an application before with the Collegeville Volunteer Fire Company:
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| Have you ever been denied membership to a fire /rescue or ems organization?:
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| Prior Fire Fighting Experience?:
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Training Type:
Please check all that apply
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| Any other training or experience?:
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Please upload copies of youc certifications:
DOC, DOCX, PDF, XLS, XLSX, PPT, PPTX, TXT, JPG, JPEG, PNG
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Current or Past Membership(s):
Are you a current or past member of another Fire / ems / Rescue organization? (If yes explain & include references.)
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| Have you ever been discharged for misconduct or unsatisfactory service or asked to resign from a fire and/or rescue/ems organization?::
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| If you have been discharged, please give details::
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| Junior Membership |
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Junior Firefighters:
Please attach working papers with this application. All Jr firefighter applicants and parents must meet with the Fire Chief
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Name(s):
List Name or Names of Parents or Legal Guardians
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Address(s):
List in same order as names
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Home Phone #:
List in same order as Names if available. If none, use XXX-XXX-XXXX
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Cell Phone #'s:
List in same order as Names
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| REFERENCES (Not Members of Collegeville Fire Company) |
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Reference #1::
Name, Address, Phone Number, Email Address,
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Reference #2::
Name, Address, Phone Number, Email Address,
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Reference #3::
Name, Address, Phone Number, Email Address,
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| Emergency Contact Information |
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Emergency Contact Information #1:
List Full Name, Address, both home and cell phone numbers. Email address(s)
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Emergency Contact Information #2:
List Full Name, Address, both home and cell phone numbers. Email address(s)
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Emergency Contact Information #3:
List Full Name, Address, both home and cell phone numbers. Email address(s)
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| MEDICAL CONTACT INFORMATION |
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| Doctors Name:
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| Doctors Phone Number:
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Allergies:
Please list any know Allergies
eg, Latex, Antibiotics etc.
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| Acknowledgement |
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How did you hear about us:
Check all that apply
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County Recruitment Program
Email
Friend
Member
Recruitment Flier
School Guidance Counselor
Social Media
State Recruitment Program
N/A
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| Child Abuse Clearance:
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| PA Criminal Background Check:
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| FEMA ID Number:
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| Last 4 Numbers of Social Security Number:
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| Please type your signature here::
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| Please Attach: PA Criminal History Background Check:
Child Abuse Clearance. Links Below. |
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Pa Criminal Background Check
Child Abuse Clearence History Clearence Check
E-Signature Disclaimer:
E-Signature Disclaimer By signing my e-signature signature above, I acknowledge and agree that my e-signature holds the same legal validity and enforceability as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act) and the Uniform Electronic Transactions Act (UETA). I consent to the use of electronic records and signatures for all forms, agreements, and transactions related to this application. By submitting my electronic signature, I signify that I have applied for membership with the Collegeville Volunteer Fire Department, that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand any intentional false statement may be grounds for dismissal from the Company. Furthermore, I hereby grant Collegeville Volunteer Fire Company permission to contact my employer, references, and any other persons or agencies who may have knowledge of me, my skills, and my experience as may be deemed necessary. I also understand that I will be required to undergo a mandatory physical, at my expense, to be considered for Operational Membership. By providing my e-signature, I confirm that I have reviewed the document, and that I understand its contents, and agree to the terms. Once submitted, my e-signature is final and legally binding. If you prefer not to use an electronic signature, please contact us to arrange an alternative signing method.
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Aug 09, 2026
