Perry Township Fire Department
Membership Application

To apply for membership please complete all questions prior to submitting the form.

Date of Birth
Note: A conviction / plea will not necessarily disqualify you for consideration.
Reference #1
Reference #2
Reference #3
To the Board of Directors of the Perry Township Volunteer Fire Department, Incorporated: I hereby certify that the information on this application is correct to the best of my knowledge. I have read the Letter to Applicant. You have my permission to contact references and to investigate my criminal and driving records and to furnish the information to any required agency. I affix my signature in evidence thereof.