Membership Application Form – Baldwin Fire Rescue

Section I – Personal Information

First Name *

MI

Last Name *

Date of Birth *

Email *

Best Phone # *

Text? YES NO

Sorry, you must be at least 14 years old to join Baldwin Fire Rescue as a junior member.

Home Address *

PA Driver’s License #

Emergency Contact Name *

Emergency Contact Phone # *

Membership Type *

Active Firefighter (A Member, 18+) Administrative Member (B Member) Junior Firefighter (C Member, 14–17) Associate Member

Section II – Employment / School

Are you currently employed?

Yes No

Name of Employer

Address of Employer

Employer Phone #

Job Title

General Availability (Weekdays / Weekends / Nights)

Are you a student (high school or college)?

Yes No

Name of School

Address of School

Section III – Criminal Background Checks

By applying to Baldwin Fire Rescue, you understand that a Pennsylvania State criminal background check will be performed at minimum prior to acceptance of membership. Additional FBI criminal background checks and Pennsylvania Child Abuse History clearances may be required under applicable law. You also understand that certain arson-related convictions prohibit service as a firefighter in Pennsylvania.

By submitting this form, you state that you have not committed any prior felony offenses, and that if a background check shows otherwise, it is grounds for immediate disqualification of membership.

I acknowledge and authorize the required criminal background checks and affirm the felony statement above.

Section IV – Prior Firefighting Experience

Do you have prior firefighting experience? *

Yes No

If you answered “Yes”, please complete the fields below.

Name, address, and phone number of previous fire company

Name of Company Chief or President

May we contact your last department?

Yes No

Reason for leaving your last department

Years / time active at last department

Section V – Emergency Services Certifications

Please list any FIRE or HAZMAT certifications that you possess:

Please list any RESCUE or MEDICAL certifications that you possess:

By stating that you possess the above certifications, you agree to present original copies upon the start of your one (1) year probationary period. Failure to do so will be considered a falsification of information on this application and may be grounds for termination of membership at the end of your probationary period.

I acknowledge the certification statement above and agree to present original documentation upon request.

Section VI – Medical Conditions

Firefighting is an ultrahazardous and physically demanding activity that also requires strong mental fortitude and the ability to make quick decisions that affect the safety of yourself and others. Having a medical condition does not automatically disqualify you from membership, but we must be aware of any conditions that could impact your safety or assignments.

Please list any and all medical conditions that you may have:

Section VII – Bylaws & Truthfulness

By applying, you agree to adhere to the Baldwin Fire Rescue bylaws. You also affirm that all information supplied on this application is truthful and complete. Any falsified information considered detrimental to firefighting or business operations of Baldwin Fire Rescue may be grounds for disqualification of membership or termination at the end of your probationary period.

If you are under 18, a parent or guardian must appear with you at the interview.

Parent / Guardian Name *

Parent / Guardian Phone # *

I agree to adhere to the BFR bylaws and affirm that all information provided is truthful and complete.