Please CLICK HERE to print: Todays date _______________
Name______________________________________________
Address_____________________________________________________________
Mailing address (if diffferent)______________________________________________
Home phone ____________________________ Cell phone (optional)____________
Birthdate (insurance purposes only _____________ Social Security #______________
Drivers license # ____________________ State _____ Class_____ Expires_______
EMPLOYMENT
Current employer___________________________ Years there ___________________
Does your employer know you applied for membership to the Juniata Fire District YES NO
Normal work hours _______________________ Could you leave work for calls YES NO
EXPERIENCE (list any experience, training, certificates, licenses etc. that are related to this field)
Hours I could respond (circle) ALL 07:00 to 17:00 17:00 to 23:00 23:00 to 07:00
Can you attend 8 meetings per year YES NO
Can you attend 12 hours of in-house training per year YES NO
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize background
investigation of information provided on this application, and driving and police records if needed for decision. I
understand this application is not intended to be a contract. In the event of acceptance, I understand that false or
misleading information given in my application, or results of background check, may result in being taken off the
Department roster. I understand, also, that I am required to abide by the rules and regulations of the Juniata Rural
Fire Protection District.
Signature________________________________ Date __________________
By State law, this application must be turned into the District Chief for submission to the Rural Board of Directors
Upon completion of this application you will be invited to the next meeting, given turnout gear, and may attend all
functions of the Department. At the completion of your six months probationary period you will be interviewed to
determine your progress and then promoted to Member status.
