Alliance Fire and Rescue Services, Inc

201 W. Broadway Red Lion, PA 17356

Fire Chief: Scott Gingrich | 717-244-8811 | President: William Berger

Select how you would like to contribute to Alliance Fire and Rescue Services

Firefighter

Fire Police

EMS

Social Member

Personal Information

Last name

First name

Middle name

Other aliases/names

Physical street address

City

State

Zip

Mailing address

City

State

Zip

Cell phone number

Home phone number

Email address

Date of birth

Month

Day

Year

Social security number

Driver's license number

State

Driver's license expiration date

License Class

Current employer

Address

City

State

Zip code

Employer phone number

Medical Information

Please list all medical information that may be critical if needed in emergency situations

Emergency Contact

Name

Relation

Address

City

State

Zip code

Phone number

Experience

Were you ever a member of another Fire or Ambulance Company?

Yes

If yes, where?

May we contact them?

Yes

Were you ever suspended or permanently removed as a member of a Fire or Ambulance Company?

Yes

If yes, why?

PLEASE PROVIDE COPIES OF ALL TRAINING COURSES COMPLETED

References and Background

Please list three references other than family and phone numbers

Have you ever been convicted of a felony and/or misdemeanor?

Yes

If yes, please list the charge, date, county, and state

Signature - Required

I understand that by signing this application, I authorize Alliance Fire and Rescue Services to make the necessary inquires in regards to the references listed in my application. I do understand that such inquires may include information to my character, public reputation, and personal characteristics. I acknowledge that the statements made on this application are true and complete. I Understand that omissions, misrepresentations, concealment and false information will result in the company withdrawing or denying my volunteer employment with Alliance Fire and Rescue Services.

The Following Items must be completed by the person applying to AFRS – Pa Criminal background and child line clearance forms. The applicant must send the forms to the appropriate addresses with the necessary fees. When the applicant receives the results, an application with copies of the results may be turned into AFRS for review by the membership committee

Applicant's signature

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Date