First name:

Last name:

Age:

Date of Birth:

Your email:

Address:

How long have you lived at this address?

Past Volunteer Service, in Other Organizations:

Reason for Leaving Previous Organization:

Number of years of volunteer service:

Are you a current member of any Volunteer Service? Yes No

Offices Held:

Have you taken in Department of Homeland Security Fire Courses?

Drivers License Number:

Drivers License Expiration Date:

EMT Number:

EMT Expiration Date:

CPR Expiration Date:

Have you ever been refused Membership in a Volunteer Organization? Yes No

What was the reason for the refusal, or expulsion?

Reference 1:

Reference 2:

Reference 3:

Do you have any known illness / disability, that may prevent you from performing your duties at Schodack Landing Fire Company? Yes No

If yes, please explain your condition:

This application is for: Active Membership Associate Membership Ladies Auxiliary