Walnut Street Fire Co. No. 4 Membership Application

Please complete this membership application form in order to be considered for membership at Walnut Street Fire Company No. 4 By sending this application you are verifying that all information provided is accurate and has not changed to the best of your knowledge. You are also giving us permission to process your application and to submit you for membership consideration.

Once we receive your completed application we will contact you via email or phone to explain the process and update you on the overall timelines for consideration. Meanwhile, if you have any questions or concerns please email us at contact@firecompany4.com.

Download and Print the Release Form

You will also need to download and complete the Request for Release of Records form. Once it’s completed and signed you can either give it to your Fire Company No. 4 sponsor(s), or we can make arrangements with you on where you can drop it off.

Request for Release of Records

Application for Membership

Please complete the following information to submit an application for membership.

Name*
First Last
Email*
Date of Birth*
MM slash DD slash YYYY

Month/Date/Year
Phone*
Address*
Street Address City State ZIP Code

Please provide your home address.
Current Employer*
Job Title / Duties*
Please briefly describe your job tasks.
How Long with Current Employer?*
Fire Department Experience
Fire department experience is not required to apply for membership.
1st Fire Department Name
How Long with this Fire Department?
2nd Fire Department Name
How Long with this Fire Department?
Fire Training Certification Level(s)
Other Fire Department Experience or Specialized Training
Please briefly explain and provide date ranges.
Background Information
High School*

Name and location (city, state).
Vocational or Tech School

Name and location (city, state).
College

Name and location (city, state).
Military Experience

Type of military and where served (if applicable).
Have Been Convicted of a Felony?*
- Yes
- No
References
(Optional)
Reference 1
First Last
Reference 1 Phone
Reference 2
First Last
Reference 2 Phone
Walnut St. Fire Co. #4 Sponsors
Name
First Last

Sponsor's Name
Name
First Last

Second Sponsor's Name
Captcha (anti-spam)

Go to the Join Fire Company No. 4 Page.

Walnut Street Fire Co. No. 4 Membership Application

Download and Print the Release Form

Application for Membership

Fire Department Experience

Background Information

References

Walnut St. Fire Co. #4 Sponsors