Pine Rock Fire Company

Shelton Volunteer Fire Company #4

Membership Application

Apply for regular, junior, or associate membership with Pine Rock Park Company 4. A member of our membership team will review your application and contact you about next steps.

Application Types

Regular Membership: Age 18+

Junior Membership: Age 15½–17

Associate Membership: Age 18+

Application Type

Select the type of membership you are applying for

Membership Type *

Applicant Information

First Name *

Middle Initial

Last Name *

Suffix

Date of Birth *

Email *

Phone *

Alternate Phone

Best Time to Contact *

Contact Preference *

Address

Address Line 1 *

Address Line 2

City *

State *

Zip *

Education

Regular applicants should complete all applicable education fields. Junior applicants only need the high school section.

High School

School Name

Location

Years Attended

Graduated?

Graduation Year

College

College Name

Location

Years Attended

Graduated?

Graduation Year

Major

Other Education

School Name

Location

Years Attended

Graduated?

Graduation Year

Major

Employment

Current Employer

Occupation / Job Title

Supervisor

Employer Address

Employer City

Employer State

Employer Zip

Duties

Emergency Service Experience

Fire Department Name

Fire Years of Service

EMS Department Name

EMS Years of Service

Police Department Name

Police Years of Service

Background Questions

Have you ever been convicted of a felony or misdemeanor? *

Do you have any medical problems which could limit your effectiveness as a firefighter? *

Please tell us why you want to become a member of Pine Rock Park Co. 4 *

Certification

I hereby certify that all statements in this application are true and complete to the best of my knowledge, and I understand that any answers or statements that I have submitted found to be false will be grounds for immediate dismissal from the company if this application is accepted.

Ready to submit?

Please review your information before sending your application.

Membership Application

Application Type

Applicant Information

Address

Parent / Guardian Information

Education

High School

College

Other Education

Employment

Emergency Service Experience

Background Questions

Certification