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Become a Member

Come join the Hepburn Township Volunteer Fire Company today and become a part of something truly special. It means you are willing to give your time to help someone in need. Its all built on family values. Our team is made up of dedicated volunteers who are passionate about serving our community. As a volunteer firefighter, you will be an important member of a team that works hard to keep our friends, families and neighbors safe. Whether you have experience as a firefighter or are interested in learning, we welcome everyone who is committed to making a difference in the world.

Our purpose here is to help our community and make it a safer place!

Join the Team

Please take a moment to fill out the application

GENERAL INFORMATION

PLEASE COMPLETE ALL INFORMATION REQUIRED For Application to be PROCESSED

Last Name, First Name, MI. (Maiden Name if applicable)

Home Address

Business or Work

Home/Work Phone

Date of Birth

Cell

Email

BACKGROUND INFORMATION

Birthplace

Level of Education

SSN

College

1

2

3

4

Degree

How long have you resided at present address?

Marital Status

Number of Children

Current Employer

Driver's License (Class)

Years of Employment

Number

Supervisor

State

Have you ever been convicted of any traffic violations?

Have you ever been convicted of any misdemeanor, summary or felony crime(s)?

Do you have any pending criminal charges?

Are you currently on parole or probation?

Please list any special skills you have

Please list any hobbies you have

HEALTH INFORMATION

Do you have any medical problems?

High Blood Pressure

Heart Problems

Diabetes

Epilepsy

Respiratory Conditions

Any other Important Medical History:

Do you have any physical problems or handicaps that may hinder you in providing emergency services?

Do you take prescribed medications?

Have you ever been treated for a nervous disorder or mental illness, drug abuse, or intoxication?

Do you wear Glsses/Contacts

Glasses

Contacts

Blood Type

If Known

Rh Positive

Rh Negative

Family Physician

Physician Phone

Physician Address

ACTIVITY INFORMATION

Would you be

available twice a month for meeting or training purposes?

able to work at fund-raising activities in the evenings and on weekends?

In what aspects of the Fire Department are you interested?

Firefighting

Rescue

Emergency Medical Tech.

Engineer (driver/pump operator)

Fire Police

Junior Fireperson

SUPPORT (assist with Fund-raising Carnival, Barbeques, etc. NO Firefighting or EMS involved)

If you would participate in the rescue service, would you take the Emergency Medical Technician Course scheduled for 12 weeks, and at least 2 nights per week?

Yes

No

List all FIRE and/or EMS organizations which you have been associated with in the past. Include any presen association. ALL past FIRE/EMS training must be included with this application. Additionally, the name, address and telephone number of the fire chief of your most recent past organization must be included.

REFERENCES

List 3 references (non-relatives) that the Fire Department may contact, i.e., Employer, Clergy, Teachers, etc.

Emergency Contact

Name, Relationship, Address, Telephone

Consent

CONSENT TO SUBMIT CRIMINAL INVESTIGATION REQUEST TO PA STATE POLICE/PROTHONOTARY

Yes

No

I hereby authorize and give consent to the Hepburn Township Volunteer Fire Company to submit a Criminal Investigation request to the Pennsylvania State Police/Lycoming County Prothonotary Office to obtain criminal history information. I understand this information must be received prior to acceptance of my application by the Fire Company Executive Board.

I certify that all information on this application, to the best of my knowledge, is TRUE and ACCURATE.

Yes

No

Thanks for submitting!

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615 East Route 973 Highway

Cogan Station, PA 17728

Tel: 570-494-0411
Fax: 570-494-2148

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