EAST ALLEN TOWNSHIP VOLUNTEER FIRE DEPARTMENT

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Date of Application:		03/14/2025 1646
Type of Membership
Membership Type:		Administrative Firefighter (18+) Junior Firefighter (14-17) Fire Police
Personal Information
Name:
Address:
City:
State:
Zip Code:
Date of Birth:
Social Security #:
Home Phone:
Mobile Phone:
Email:
Driver's License #:
Driver's License Class:		Class A Class B Class C N/A
Employment (complete all fields if currently employed)
Current Employer:
Employer Address:
Position:
Years of Employment:
Supervisor:
Phone Number:
Emergency Contacts (provide at least 1)
Emergency Contact #1 Name:
Emergency Contact #1 Phone:
Emergency Contact #1 Relationship:
Emergency Contact #2 Name:
Emergency Contact #2 Phone:
Emergency Contact #2 Relationship:
Previous Experience (list any previous agencies or organizations)
Previous Fire or EMS Experience:		Yes No
Prior Affiliations/Membership: Please list any agencies or organizations you've been a member of.
Current Certifications: (Click all that apply)		Firefighter I Firefighter II Haz-Mat: Awareness Haz-Mat: Operations Vehicle Rescue: Awareness Vehicle Rescue: Operations Vehicle Rescue: Technician CPR/AED First Aid Emergency Medical Responder (EMR) Emergency Medical Technician-Basic Emergency Medical Technician- Advanced Emergency Medical Technician-Paramedic
Education
High School:
Graduated:		Yes No (GED) Still in School
Trade School:
Trade School Certification:
College:
Degree:		Associates Bachelors Masters Still Attending
Junior Member Applicants (applicants under 18 ONLY)
Parent/Guardian Name:
Parent/Guardian Relationship:
Parent/Guardian Phone:
Criminal Background
Motor Vehicle: (please list any violations)
Criminal: (please list any criminal violations)
Background Checks: (a complete motor vehicle, criminal, arson, and child abuse background check will be completed)		Agree Not Agree
References
Reference #1 Name:
Reference #1 Phone:
Reference #1 Relationship:
Reference #2 Name:
Reference #2 Phone:
Reference #2 Relationship: