THOMPSON HOSE COMPANY PO BOX 419 53 Water St. THOMPSON PA 18465 APPLICATION FOR MEMBERSHIP Name:__________________________ Social Security No.:______-_____-_________ Address:_______________________________________ Date if Birth:___/___/_____ City/State:______________________________________ Zip Code:______________ Home Phone Number:____________________________________ Drivers License Number:____________________ State:_______ Exp. Date:_________ Emergency Contact:________________________ Phone Number:________________ Employer:________________________________ Phone Number:________________ Position:_________________________________ Hours Working:_______ to _______ Previous or Present Emergency Service:_______________________________________ Position or Rank Held: _______________________ How Long:_________________ ************************************************************************ Please explain briefly why you wish to join Thompson Hose Company, Inc. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please list two personal references other than immediate family members: Name:________________________________ Address:___________________________ Name:________________________________ Address:___________________________ I _____________________ understand Thompson Hose Company, Inc. will verify any and all information supplied by me on this application for membership. In addition I understand that if there is any question the Thompson Hose Company my request a Criminal Background Check and/or Child Abuse Clearances at the fire companies expense. All information supplied on this application is true and accurate to the best of my knowledge. I understand that any falsified information supplied on this application for membership may be cause for immediate rejection of this application. The annual membership dues are $5.00 per year. The first years dues MUST accompany this application. Should this application for membership be rejected, the dues received with this application are refundable. Membership applied for: _____ACTIVE _____CONTRIBUTORY _____ASSOCIATE _____ Auxiliary First years dues attached: _____ YES _____ NO Signature of applicant:____________________________________ Date:__________ Sponsor 1 :_______________________ Sponsor 2:____________________________ TO BE FILLED IN BY THOMPSON HOSE COMPANY, INC. Application Status: _____Accepted _____ Rejected Date:____________________ Committee Recommendations: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________.