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 _________________