Chester Hose Company Inc. P.O. Box 214 Chester, Connecticut 06412
|
Chester Hose Company Inc. P.O. Box 214 Chester, Connecticut 06412
|
|
CHESTER HOSE CO. INC.Type of Membership: please circle the appropriate category: Fire EMS Junior Honorary Other This form is to be completed by the Proposer and the Applicant and filed with the Secretary at a regular meeting of the Chester Hose Co. Inc. Page 2 of this form is for recording action taken by the Chester Hose Co. Inc. on this application. _________________________________________________ , an active member of the Hose Co. in good standing, proposes for membership in the Chester Hose Co. Inc.: Name ____________________________________ Occupation _____________________________ Address __________________________________ Employer _______________________________ _________________________________________ Business Address ________________________ Mailing Address ____________________________ ________________________________________ _________________________________________ How long have you been employed by your present employer? ____________________ Home Phone Number _______________________ Work Phone Number ______________________ Number of Dependents ______________________ Drivers License Number ____________________ Birth date _________________________________ Social Security Number ____________________ Formal Education ______________________________________________________________________ Fire Service Experience _________________________________________________________________ _____________________________________________________________________________________ Physical ailments or disabilities __________________________________________________________ Are you willing to take a physical exam by the Chester Hose Co. Inc. Physician? __________________ I realize that if I am accepted for membership in the Chester Hose Co. Inc. that I will be giving part of my time to public service. I further realize that the Chester Hose Co. Inc. is not a social club and that as a member I will be required to give freely of my time to attend fires, meetings, training drills and work on committees. Applicant’s Signature ________________________________________________ Date ____________ Proposer’s Signature ________________________________________________ Date ____________ |
|
