East Greenbush Volunteer Fire Company, Inc.
68 Phillips Road Rensselaer, NY 12144 518-477-6503 ; 518-479-4168 Fax:518-477-2319 APPLICATION FOR MEMBERSHIP A candidate for Active Membership whall be at least seventeen years of age and shall reside or be gainfully employed within the territory of East Greenbush Fire District Number 3 or territory under contract with East Greenbush Fire District Number 3. ~ Article 2, Section 2, Paragraph 1 of the East Greenubsh Fire Company Bylaws ~
Personal Information:
Applicant Name:
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Mailing Address Fields (leave blank if same as Present Address Above
Mailing Address:
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Have you previously submitted an application to the East Greenbush Fire Company?	yes no
If yes, please indicate the date::
Emergency Contact Name and Relationship:
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Employment Information:
Current Employer:
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If you are employed within EGFD will your employer allow you to leave work to respond to calls	yes no
Education:
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Military Service: If none, leave this section blank.
Military Service:	yes no
If yes, please explain:
Induction Date:
Discharge Date:
Discharge Honorable:	yes no
Discharge Other:
Branch:
Active/Reserve:	active reserve
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Medical Information:
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