PERSEVERANCE VO= LUNTEER FIRE COMPANY

&nb= sp;

= MEMBERSHIP APPL= ICATION

&nb= sp;

= ACTIVE FIREFIGHTER

INSTRUCTIONS: 1. Fill out pages 1 through 4.<= span style=3D'mso-spacerun:yes'> Applicant to sign page 4 and also = have

their spouse sign (if applicable) and if the applicant= has a fire

company member as a sponsor, the sponsor should also s= ign page 4.

All signatu= res should also be dated.

2.&n= bsp; Page 5 is a release so the Souderton Borough Police Dept. may do a

back ground check if requested= by the fire company. Applicant must

sign the appropriate release a= nd this must be witnessed by an officer of the Perseverance Volunteer Fire Company.

3.&n= bsp; The last page is for requesting a back ground check through the

Pennsylvania State P= olice. The applicant shall submit $10.00 to the

fire company which will accomp= any this request to the state police.

If the applicant is accepted and completes the 6 month probationary

Period, the $10.00 will be reimbursed to the applicant.

&= nbsp;

= &nb= sp; = P E R S E V E R A N C E

= &nb= sp; = VOLUNTEER FIRE CO. NO. 1

= &nb= sp; = 266 NORTH SECOND STREET

= &nb= sp; = &nb= sp; SOUDERTON, PA. 18964

= = APPLICATION FOR ACTIVE MEMBERSHIP

PERSONAL INFORMATION

A.&n= bsp; NAME: &= nbsp; &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = = PHONE NUMB= ER &n= bsp; = ; &n= bsp;

        =             &nb= sp;            =             &nb= sp;    (LAST)        =             &nb= sp;            =     (FIRST)        =             &nb= sp;       (MIDDLE)

B.&n= bsp;      PRESENT ADDRESS:        &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;

C.&n= bsp;     HOW LON= G HAVE YOU RESIDED THERE?   &n= bsp;      <= span style=3D'color:silver'>   &n= bsp;              YEARS &n= bsp; =              MONTHS        &n= bsp;

D.      PREVIOUS ADDRESSES:   1.           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;

      = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;     2.           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;

E.&n= bsp;      DATE OF BIRTH:           &= nbsp;           &nbs= p;            &= nbsp;           &= nbsp;               = MARITAL STATUS:     =         &= nbsp;          SINGLE:

=             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =               &= nbsp;         &= nbsp;         MARRIED:

=             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =              &= nbsp;         &= nbsp;         SEPERATED:

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

F.=     SOCIAL SECURITY NUMBER:           &= nbsp;           &nbs= p;            &= nbsp;

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OPERATOR’S LICENSE INFORMATION

A.&nbs= p;   OPERATOR LICENSE NUMBER:   =    &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;

B.&nbs= p;   ADDRESS ON LICENSE:      &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;

C.&n= bsp;     RESTRIC= TIONS: &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;             &= nbsp;       D.&nb= sp; CLASSES:   =    &n= bsp;            = ;

E.&nbs= p;   EXPIRATION DATE:      &n= bsp;            = ;            &n= bsp;            = ;

F.   = LICENSE EVER BEEN SUSPENDED?    HAVE THEY BEEN RE-INSTATED?     EXPLAIN IN DETAI= L

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        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     PAGE 1 OF 5=

EMPLOYMENT INFORMATION

A.       = PRESENT EMPLOYER:        &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;

= ;

B.&n= bsp;      SUPERVISOR’S&n= bsp; NAME:       &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;

C.    TEL= EPHONE NUMBER:           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

D.    <= st1:place w:st=3D"on">NORMAL WORKING HOURS:       &n= bsp;             to            .

= ;

E.    HOW LONG EMPLOYED:   =    &n= bsp;           &= nbsp;         t= o   &nbs= p;         .=

F.    PRE= VIOUS EMPLOYER:          =         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

EMERGENCY INFORMATION

A.&n= bsp;      IN CASE= OF EMERGENCY NOTIFY:   &nbs= p;    &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;                &= nbsp;           &nbs= p;           =

B.&n= bsp;      RELATIONSHIP: =    &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;    &n= bsp;            C. PHONE N= UMBER:   &nb= sp;        &n= bsp;            = ;            &n= bsp;

= ;

D. = ;   LIST ANY CHRONIC AILMENTS,&= nbsp; PHYSICAL DISABILITES OR PROLONGED ILLNESS.<= o:p>

        &= nbsp;           &nbs= p;   LIST ANY DATES OF ILLNESS.<= /span>

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

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

E. = ;   FAMILY PHYSICIA= N:   &n= bsp;             =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &nb= sp;            =                 &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;               (NAME)        =             &nb= sp;             (ADDRESS)        =             &nb= sp;            =             (PHONE)

F. = ;   DATE OF LAST PHYSICAL:       &n= bsp;            = ;            &n= bsp;

G     PHYSICIAN PERFORM= ING PHYSICAL:           &= nbsp;            =                 &= nbsp;           &nbs= p;              &n= bsp;            PHONE:         &= nbsp;           &nbs= p;

CRIMINAL HISTORY INFORMATION   &nb= sp;

A.    HAVE YOU EVER BEEN ARRE= STED FOR ANY CRIMINAL ACTIVITY?   IF SO, LIST THE

        ARRESTING AGENCY, D= ATE, NATURE OF THE INCIDENT AND THE FIN= AL DISPOSITION

        OF THE INFRACTION.&nb= sp; (DO NOT INCLUDE MOTOR V= EHICLE VIOLATIONS).

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

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =         &= nbsp;

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

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           &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;           PAGE 2 OF 5=

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B.    DO YOU HAVE AND PENDING CRIMINAL CHARGES?   IF SO, PLEASE EXPLAIN IN DETAIL.

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

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

= ;

PRIOR FIREFIGHTING EXPERIENCE

<= span style=3D'text-decoration:none'>

A.       = HAVE YOU EVER BEEN A MEMBER OF ANY OTHER FIRE COMPANY= ?    <= /span>   &n= bsp;            = ;

= ;

B.    IF SO, NAME OF FIRE COM= PANY:   &n= bsp;             =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             <= /span>

C.    LIST ANY & ALL FIRE FIGHTING CREDENTIALS:

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

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            = ;                =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

SERVIC= E & CIVIC ORGANIZATIONS

A.       = LIST ANY SERVICE OR CIVIC ORGANIZATION THAT YOU ARE CURRENTLY A MEMBER

        OF OR HAVE BEEN A MEMBER OF.   = PLEASE INCLUDE THE DATE YOU JOINED AND, IF

        APPLICABLE, THE= DATE AND REASON OF TERMINATION.

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

   &n= bsp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =

I, THE UNDER SIGNED, DO HEREBY AFFIX MY SIGNATURE CL= AIMING THE INFORMATION CONTAINED

HEREIN TO BE TRUE AND CORRECT TO THE BEST OF MY KNOW= LEDGE AND DO UNDERSTAND THAT ANY MISREPRESENTATION OF FACTS CONTAINED HEREIN WILL RESULT IN AN IMMEDIATE EXPUSLSION

FROM THE PERSEVERANCE VOLUNTEER FIRE COMPANY.

= ;

WHEREAS, I= FURTHER STATE THAT I ACCEPT ANY AND ALL EQUIPMENT DESIGNATED TO ME AS THE

EQUIPMENT = OF THE PERSEVERANCE VOLUNTEER FIRE COMPANY AND DO FULLY UNDERSTAND THAT

THESE ITEM= S ARE MY RESPONSIBILITY IN SO MUCH AS THE MAINTENANCE AND GENERAL CARE OF THIS EQUIP= MENT IS MY RESPONSIBILITY. I FURTH= ER UNDERSTAND THAT THIS EQUIPMENT IS TO BE

RETURNED I= N ITS ENTIRETY UPON MY RESIGNATION OR TERMINATION FROM THE PERSEVERANCE<= /i>

VOLUNTEER = FIRE COMPANY.

= ;

= ;

        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     PAGE 3 OF 5

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WHEREAS, I= FURTHER STATE THAT I AM AWARE THAT ANY CONSUMPTION OF ANY TYPE OF AN

INTOXICATI= NG BEVERAGE AT ANY FUNCTION OF THE PERSEVERANCE VOLUNTEER FIRE COMPANY

BEFORE I A= M OF LEGAL AGE AND MANDATORY AGE TO CONSUME SAME BEVERAGE WILL RESULT IN THE

IMMEDIATE EXPULSION FROM THE PERSEVERANCE VOLUNTEER FIRE COMPANY.

= ;

WHEREAS, I= DO ATTEST BY MY SIGNATURE THAT I AM AWARE AS MANDATED BY THE BY-LAWS OF

THE PERSEV= ERANCE VOLUNTEER FIRE COMPANY THAT I ATTEND ANY AND ALL PRACTICE SESSIONS AND MEET= INGS AS SO CALLED FOR AND THAT I PRESENT MYSELF IN A MANNER OF RESPECT AND DIGNITY TO UPHOLD THE INTEGRI= TY OF THE PERSEVERANCE VOLUNTEER FIRE COMPANY AT ALL TIMES.=

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   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;        &n= bsp;            = ;            &n= bsp;           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

SIGNATURE OF APPLICANT     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp; DATE

   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;        &n= bsp;            = ;            &n= bsp;           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

SIGNATURE OF SPOUSE       (IF APPLICABLE)   &nb= sp;            =             &nb= sp;            =          DATE

   &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;        &n= bsp;            = ;            &n= bsp;           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

SIGNATURE OF SPONSOR      =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =     DATE

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        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     PAGE 4 OF 5

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

I, THE UND= ERSIGNED, DO STATE THAT BY MY SIGNATURE I PERMIT AND AUTHORIZE THE OFFICERS OF THE PERSEVERANCE VOLUNTEER FIRE COMPANY OR WHOMEVER THEY MAY DESIGNATE TO HAVE ACCESS TO AND/OR HAVE RELEASED TO THOSE PERSONS ANY AND ALL INFORMATION REGARDING THE CONTENTS OF THIS APPLICATION.

= ;

I DO HEREBY AND FREELY RELINQUISH THE SOUDERTON BOROUGH POLICE DEPARTMENT OF ANY RESPONSIBILITY DURING THEIR INVESTIGATION OF ANY PAST CRIMINAL ACTIVITY

AND DO WIL= LINGLY SUBMIT MY FINGERPRINTS TO THE SOUDERTON BOROUGH POLICE DEPARTMENT FOR BOTH INVESTIGATIVE AND FILE PURPOSES.

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

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

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp; SIGNATURE OF APPLICANT     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;       DATE

&nbs= p;

&nbs= p;

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

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp; WITNESS   (FIRE COMPANY OFFICER)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p; DATE

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I, THE UNDERSIGNED, AM UNDER THE AGE OF 21. I DO HEREBY AND FREELY AUTHORIZE

THE SOUDER= TON BOROUGH POLICE DEPARTMENT TO HAVE ACCESS TO ANY CRIMINAL RECORDS PRIOR TO MY AGE OF 18. I RELINGUISH THE SOUDERTON BOROUGH POLICE DEPARTMENT OF ANY RESPONSIBILITY DURING THEIR INVESTIGATION = OF ANY PAST CRIMINAL ACTIVITY.

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        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;                 &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;                 &= nbsp;               &= nbsp;           &nbs= p;           <= o:p>

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;         SIGNATURE OF APPLICANT     &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;       DATE

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

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;         WITNESS (FIRE COMPANY OFFICER)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p; DATE

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        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     PAGE 5 OF 5

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