Personal Information
Last Name
First Name
 Middle
Address
 Apartment #
City
Zip Code
 State
Home Phone
 Alternate Phone
Birth Month
 Birth Date
 Birth Year
Social Security
Number
Marital Status
License
Suspended?
Driver License #
 State
Do You own a
motor vehicle?
What Driver License Class(es) to you possess?
Employment and Education
Are You
Employed?
Current
Employer
Occupation
Are You Enrolled
in School?
School Attending
Highest Education Level
Background and Medical Information
Have You Been Arrested?
If Yes, Who was the
arresting department?
If you were arrested, please explain the
reason for the arrest, when the arrest
occurred, and disposition of the case
Do you have any
medical conditions?
If yes, please explain
Firefighting and Membership Background
Have you ever been a
member at another Fire Dept?
If Yes, Which Department
Dept Phone #
 Chief's Name
Years at that Dept
 Title(s) Held at that
Department
List any Major Certificates / Certifications Held.  
(ie; Essentials, FFI, etc)
Membership Type and Signature
Membership Type Requested
By Initialing and Dating this form, I hereby give permission to Cherry City Volunteer Fire Company to
process my application and request a criminal background check through PA Act 33
Initials of Requestor
Date Submitted: