Volunteer Application – Tri-Hampton Rescue Squad

First Name

Middle Name

Last Name

Date of Birth

Social Security Number

Address

City & State

Zip Code

Home Phone

Work Phone

Cell Phone

High School Graduate (Yes/No)

Graduation Date (Or Anticipated)

Name of High School

GED?

ENTER BELOW ANY COLLEGES, UNIVERSITIES OR TECHNICAL SCHOOLS ATTENDED

Pennsylvania Drivers License #

Other Permits Held

Current # of Points (If any)

Class of License

Driving Restrictions (If any)

Has your license ever been revoked?

Have you ever been convicted of a felony? (YES/NO)

If yes, please give exact details (conviction, offenses, location of offense, sentencing court, date of sentence and nature of sentence.)

Have you previously served in a volunteer emergency service? (circle one)

If yes, where and when?

Do you have any military experience?

BRANCH

Years of Service

Type of Discharge

Date of Discharge

Please list any school honors, organization memberships unique skills etc...

Please list any members of THRS that you know

Please list any additional information you consider pertinent to your application for membership

Reference #1 Name

Reference #1 Phone

Reference #2 Name

Reference #2 Phone

Reference #1 Address

Reference #1 City & State

Reference #1 Zip Code

Reference #2 Address

Reference #2 City & State

Reference #2 Zip Code

Please attach your typed Cover Letter (PDF or Word Doc)

Please attach your Resume (PDF or Word Doc)

My Signature Below Indicates that I have Read, Understand and Consent to the above Statements. The Authorization or Photocopy shall serve as a consent for the Tri Hampton Rescue Squad to request any information concerning my application.

Signature Date