Nittany Valley Volunteer Fire Company, Inc.
5101 Nittany Valley Drive, P.O. Box 508
Lamar, Pennsylvania 16848

(570) 726-6884
www.nittanyvalleyfire.com 

APPLICATION FOR MEMBERSHIP 

Name ___________________________________________________________  

Phone # (_____)___________________________________________________

Mailing Address ___________________________________________________
City _____________________ State _______ ZIP Code __________________

Physical Address __________________________________________________
City _____________________ State _______ ZIP Code __________________

Are you age 18 or older?   Yes / No   If not what is your age? _______    
Date of birth ______/______/______

Do you have a valid PA driver’s license?   Yes / No  

Current driver license # ______________________________________________
Expiration Date ______/______/______

Have your driving privileges ever been suspended or revoked in PA or any other state?   Yes / No

If you answered yes to the above question please explain:
(use the back of this paper if more room is needed)

_________________________________________________________________

_________________________________________________________________

Have you ever been arrested?   Yes / No   If yes please explain: _________________________________________________________________ 

_________________________________________________________________

Have you ever been or are you currently a member of any other fire company or ambulance company?    Yes / No

If yes: Name of company ________________________________________
Phone # (_____)______________________________________________

Address _________________________________
City ______________________ State _______ ZIP Code ______________

Name of your employer _________________________________________ 
Phone # (_____)_______________________________________________

Address _____________________________________________________
City ________________________ State ______ ZIP Code _____________

May we contact your employer    Yes / No       If no, why? ____________________________________________________________

 How long have you been at your present job? 
Year’s _________ Months _______________________________________

Please list 3 references who are not related to you or living with you.

Name ________________________________________________________
Phone # (_____)________________________________________________

Address ______________________________________________________
City _________________________ State ______ ZIP Code _____________

Name ________________________________________________________
Phone # (_____)________________________________________________

Address ______________________________________________________
City _________________________ State ______ ZIP Code _____________

Name _________________________________________________________
Phone # (_____)_________________________________________________

Address ________________________________________________________
City _________________________ State ______ ZIP Code _______________

Please list three other organizations that you have belonged to in the past five years, please note this section is optional:

1.      ______________________________________________________________

2.      ______________________________________________________________

3.      ______________________________________________________________  
By signing this application for membership, I agree to be governed by the by-laws, polices, S.O.P’s, and S.O.G’s of the Nittany Valley Volunteer Fire Company, Inc. and by any local, state or federal laws that apply.

   Falsification of any information on this application shall be grounds for immediate expulsion from the Nittany Valley Volunteer Fire Company, Inc.

   By signing this application for membership I give the Membership Committee of the Nittany Valley Volunteer Fire Company, Inc. or its designee full permission to perform a background check, including but not limited to contacting my references and criminal background check through local, state and federal law enforcement agencies.

   This application must have signatures from two (2) Active or Life Members of the Nittany Valley Volunteer Fire Co. before the applicant or the application will be considered for membership.

Applicant’s signature:________________________________________________
Date ____________________________________________________________

Sponsor's signature:__________________________________________________
Date ____________________________________________________________

Sponsor's signature: _________________________________________________ Date _____________________________________________________________

The Nittany Valley Volunteer Fire Company, Inc. reserves the right to reject any applicant or application.

The Nittany Valley Volunteer Fire Company, Inc. does not discriminate against any person for race, color, religion or gender.

For fire department use only

Applicant was (circle one) accepted / rejected on  ______/______/______

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