Fly Creek Volunteer Fire Company

P.O. Box 218

Fly Creek, NY 13337


Application for Membership

                                                          (Please Print)

Name __________________________________________

               FIRST                       M.I.                     LAST

Address ________________________________________


Telephone _______________________________________

                       Home                                                       Mobile

Email __________________________________________


Social Security # _________________________________


Date of Birth ____________________________________


Driver License # __________________________________


                           1) Are you a resident of the Fly Creek Fire District?      Yes        No

                            2) Have you had any Fire or EMS training?                    Yes       No

3) What interests do you have in the Fire Service?

                                          (circle all that apply)


I hereby pledge to attend meetings, drills, fires, medical emergencies, etc. (when available).

I further pledge to follow all the Bylaws of the Fly Creek Volunteer Fire Company

and attend the mandatory training classes as required in the Bylaws.


___________________________________________            ________________________

              Applicant’s Signature                                                                     Date


NOTICE: New York State Law mandates that all applicants to a Volunteer Fire Service must submit to firefighter arson and

driver’s license background check before they can become a member of any Fire/EMS squad, department, company or service.