<>

FIRE SERVICE WOMEN OF NEW JERSEY

                                                            Application for Membership                                 REGION                       

 

ARE YOU:    A NEW MEMBER             ,  RENEWING                ,  UPDATING INFO ______         

      

Name:                                                                                                                                                                                                                                                                                                                                                                       

Home Address:                                                                                                                                                                                                                                                                                                                                         

City:                                                                   State:                                   Zip:                            County:                                                               

Home Phone:                                                   Business Phone:                                                  Fax:                                         

 

Date of Birth:                                                    E-mail Address:                                      __________________________                                          

 

Fire Department:                                                                                                                                                                                                                                                                                                                          

Address:                                                                                                                                                                                                                                                                                                                                                          

City:                                                                   State:                                  Zip:                            County:                                                                    

Position:                                                                                                         How Long:                                                                                                              

Please send correspondence to my:                      Home            Fire Department

 

 

Which best describes your role in the Emergency Services:  (Check all that apply)

 

          Firefighter   Volunteer/Paid                     Fire Investigator                             Fire Sub-Code Official

 

          Fire Inspector/Official                                Fire Officer   (rank)                                                              

 

_____Fire Instructor                                             Insurance                                     __ E.M.T.   _____ FF1   

 

_____EMT Instructor                                 _____EMT Officer  (rank)                                                                      

 

 

I hereby apply for membership in the Fire Service Women of New Jersey and I agree to abide by the By-Laws of the Organization.

 

Signature of Applicant:                                                                                               Date:                                                                                                              

Dues are $20.00 for one year and must accompany the application.

Make checks payable to: Fire Service Women of New Jersey

                                              

Mail check and application to:

  

Fire Service Women of New Jersey

C/o Secretary

31 Central Avenue

Pittsgrove, NJ 08313

OFFICIAL USE ONLY

 

    Date Received:_________________                   Approved:     Yes      No                   Region #:                                          

    Check #:______________________                    Cash:__________________

 

   Signature of Treasurer:                                                                                                       Date _________________