Horseheads Fire & Rescue

134 North Main Street

Horseheads, New York

14845

Application for membership

Name__________________________      ___          ___________________________

                        (Last)                                  (MI)                                (First)

Address________________________________________________________________

City_________________________   State____________   Zip____________________

Phone (____) _________________

Date of birth__________________  Please list below, any education related to Fire Science, First Aid, or other specialized training.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

I realize that if ____________________ is accepted for membership in the Horseheads Fire Department, he/she will giving part of their time to public service.  I further realize that giving some form of public service is the duty of every citizen and I hereby give my consent to this application.

Signature of parent or guardian____________________________

The information contained in this application is true to the best of my knowledge and belief and I understand and agree that any misrepresentation or false statement by me in connection with the application will constitute justifiable cause for the Horseheads Fire Department to terminate my membership.

I understand and agree that all information furnished in this application may be verified by the Horseheads Fire Department.  I hereby authorize all individuals and organizations to give the Horseheads Fire Department all information relative to such organizations and release the Horseheads Fire Department from any and all liability for any claim or damage resulting there from.  

If elected to membership, I agree I will serve at the will of the Company and the Department.  I agree that the rules, policies and regulations of the Company and Department shall bind me, as they are from time to time changed with proper notification to me.

            Applicant’s Signature______________________   Date___________