= APPLICATION FOR JR. FIRE FIGHTER <= /p>

= ACTIVE MEMBERSHIP

PERSONAL INFORMATION

A. NAME: _______________________________________________ PHONE: ______ &nbs= p; _____

= &nb= sp; (Las= t) = &nb= sp; (First) = &nb= sp; (Middle)

B. PRESENT ADDRESS: __&nbs= p; &= nbsp; __________ &= nbsp; &nbs= p; __________

= &nb= sp; = &nb= sp; _____________ &= nbsp; &nbs= p; &= nbsp; &nbs= p; __________

= &nb= sp;

C. HOW LONG HAVE YOU RESIDED THERE: _________ = Yr. = ________Mo.

D. PREVIOUS ADDRESS: &n= bsp; 1. __________________________________________________=

= &nb= sp; = &nb= sp; = 2. __________________________________________________=

E. DATE OF BIRTH: _________________ = MARITAL STATUS: ____ Single

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &= nbsp; ____ Married

&= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; = &= nbsp;

F. SOCIAL SECURITY NUMBER: ___________________________<= o:p>

OPERATOR' LICENSE INFORMATION

A. OPERATOR LICENSE NUMBER: _________________________

B. ADDRESS ON LICENSE: ________________________________

= C. RESTRICTIONS: ______________________________________ &= nbsp;

= D. CLASS: ________<= /p>

E. EXPIRATION DATE: __________________________

SCHOOL INFORMATION<= /u>

A. CURRENT GRADE: ______ &= nbsp; &nbs= p; B. CURRENT GRADE AVERAGE: _____= ____

= &nb= sp; = &nb= sp; = &nb= sp; = (All Classes Together)

C. SCHOOL ATTENDING: &= nbsp; SOUDERTON AREAHIGH ________= __

= &nb= sp; = &nb= sp; = NORTH MONTCO TECH ____________

= &nb= sp; = &nb= sp; = OTHER _____________________<= o:p>

D. COUNSELOR'S NAME: ___________________________ <= span style=3D'mso-tab-count:1'> PHONE: ________________=

E. NORMAL SCHOOL HOURS: __________ TO __________=

= &nb= sp; =

F. DO YOU PARTICIPATE IN ANY SCHOOL ACTIVITIES? YES: _____ NO: _= ____

= (IF YES, PLEASE LIST THE ACTIVITIES BELOW)

= = _________________________________________________= _________________

EMPLOYMENT INFORMATION= :

A. DO YOU PRESENTLY HAVE A FULL= OR PART TIME JOB? YES: ___= __ NO: _____<= /p>

(IF YES, PLEASE ANSWER THE QUESTIONS BELOW)

B. EMPLOYER: ______________________________ B. PHONE: ______________

C. EMPLOYER'S ADDRESS: ______________________________________________

D. NORMAL WORKING HOURS: _______ To _______

E. HOW LONG EMPLOYED: ______Yr. ______ Mo.

EMERGENCY INFORMATION<= /b>:

     A.   IN CASE OF AN EMERGENCY NOTI= FY:

        &= nbsp;   NAME: _______________________ RELATIONSHIP: ____________   PHONE: ____________

        &= nbsp;   NAME: _______________________ RELATIONSHIP: ____________ PHONE: ____________

     B.   LIST ANY CHRONIC AILMENTS, PHYSICAL DISABILITES OR PROLONGED

        =     ILLINESS AND DATES:

  =             &nb= sp;         ________________= _______________________________________________

        =           =             &nb= sp;     ________________________________________= _______________________

        =          =        _______________________________= ________________________________

     C.   FAMILY PHYSICIAN: __________________________________________            =           _________= _____

        =             &nb= sp;            =             &nb= sp;            (NAME)        =         =            (A= DDRESS)        =             &nb= sp;           (PHONE)

     D.   DATE OF LAST PHYSICAL: _______________

     E.   PHYSICAN PERFOR= MING PHYSICAL: ________________________ &n= bsp; PHONE: __________

CRIMINAL HISTORY INFORMATION:

     A.   HAVE YOU EVER BEEN ARRESTED = FOR ANY CRIMINAL ACTIVITY?

        =           IF SO, LIST THE ARRESTING AGENCY, DATE, NATURE OF THE INCIDENT AND <= o:p>

        =           THE FINAL DISPOSITION OF SAID INFRACTION.   (DO NOT INCLUDE MOTOR

                 VEHICLE VIO= LATIONS)

  =             &nb= sp;         ________________= __________________________________________

  =             &nb= sp;         ________________= __________________________________________

  =             &nb= sp;         ________________= __________________________________________

     B.   DO YOU HAVE ANY PENDING CRIM= INAL CHARGES?

            =        IF YES, EXPLAIN IN DETAIL:

  =             &nb= sp;         ________________= _______________________________________________________

  =             &nb= sp;                 =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;

  =             &nb= sp;                 =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;

         = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;

  = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;

PRIOR FIRE FIGHTING EXPERIENCE:<= /o:p>

     A.   HAVE YOU EVER BEEN A MEMBER = OF ANY OTHER FIRE COMPANY, AMBULANCE

        =     ORGANIZATION OR RESCUE SQUAD?     ____________

     B.   NAME OF COMPANY, ADDRESS &am= p; PHONE NUMBER:

  =           _____________= _______________________________________________________________<= /span>

  =             &nb= sp;                      &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;

     C.   LIST ANY/ALL FIRE FIGHTING CREDENTIALS AND IF YOU SERVED AS A JR.

        =     IN ANY COMPANY.

  =           _____________= _____________        &= nbsp;           &nbs= p;            &= nbsp;          ____= _________________________

         =    __________________________        ____________________        &= nbsp;           &nbs= p;           _= _________

         =            &= nbsp;           &nbs= p;   _________________________________________________= _____________

SERVICE & CIVIC ORGANIZATIONS

     A.   LIST AND SERVICE ORGANIZATIO= NS THAT YOU ARE PRESENTLY A MEMEBER OF

        =     OR HAVE BEEN A MEMBER OF. INCLUDE THE DATES YOU WERE A MEMBER.

        =     (DO NOT INCLUDE SCHOOL ORGANIZATIONS. THIS WOULD BE LIKE THE BOY

SCOUTS, CAP, ETC.)     ____________________________________________________________________= _____

        =      ____________________________________________________________________= _____

        =      ____________________________________________________________________= _____

I, the undersigned, do hereby affix my signa= ture claiming the information contained herein to be true and correct to the bes= t of my knowledge and do understand that any misrepresentation of facts contained herein will result in an immediate expulsion from the = Perseverence Vol. Fire Co.

Whereas I further state that I accept any and all equipment designated to me as the equipment of the Perseverence Vol. Fire Co. and do fully understand that these items are my responsibilit= y in so much as the maintenance and general care of this equipment and must be returned in its entirety upon my resignation or termination from the Perseverence Vol. Fire Co.

I further state that I am aware that any consumption of any type of an intoxicating beverage at any function of the = Perseverence Vol. Fire Co. before I am of legal age a= nd mandatory age to consume same beverage will result in the immediate expulsi= on from the Perseverence Vol. Fire Co.<= /span>

Whereas, I do attest by my signature, that I= am aware as mandated by the by-laws of the Perseverence Vol. Fire Co. that I attend any and all practice sessions and meetings, exc= ept as restricted by the

Rules & Regulations governing JR. firefighters, as so called for and that I present myself in a manner of respect and digni= ty to uphold the integrity of the Perseverence Vol= . Fire Co.

I also state, that I have thoroughly read the "Rules & Regulations" for Jr. firefighters attach= ed to this

application= and the same were reviewed by my parents/guardians.

SIGNATURE OF JR. APPLICANT: _______________________________ DATE= :   __________=

SIGNATURE OF SPOUSE: ______________________________________       DATE= :   __________=

   ( If&nbs= p; Applicable)

SIGNATURE OF SPONSOR: __________________________________= ___        &= nbsp; DATE:   __________=

SIGNATURE OF PARENT/GUARDIAN: ___________________________        &= nbsp;   DATE:   __________=

  =             &nb= sp;            =             &nb= sp;                =           ___________________________ &nb= sp;          DATE:   __________=

  =             &nb= sp;            =             &nb= sp;                =             RELEASE

I, the undersigned, do state that by my signature I permit the administrative officer for Jr.

firefighters to contact my counselor and t= he counselor may release information on my grades and

conduct in school. When such information is released, this information shall be kept confidential

by the administrative officer.

SIGNATURE OF STUDENT: _______________________________  =           DATE: _____________

As parents/guardians of<= span style=3D'mso-spacerun:yes'> __________________________ = , we authorize the administrative

officer for Jr. firefighters to contact the counselor and the counselor may release information on

our<= span style=3D'font-size:11.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New = Roman"'> son/daughter's grades and con= duct in school. We understand that this information will be

kept= confidential by the administrative officer.

PARENTS/GUARDIANS:    ______________________= __________        &= nbsp;   DATE: _____________

  =             &nb= sp;            =                  ________________________________      DATE: _____________

  =             &nb= sp;