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Medway-Grapeville Fire District Membership Application
Submit this application online and someone will follow up with you to complete the membership process.
All information will be held in the strictest confidence. Any false or misleading information given in this application may be considered grounds for denial or dismissal.
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Email
*
Your email
Name:
*
Your answer
Address:
*
Your answer
Phone Number:
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Location of Birth
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Your answer
Drivers License State and Number (ex. NY 123 456 789)
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Your answer
Drivers License Expiration Date:
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MM
/
DD
/
YYYY
Have you ever been, or are you now an active member of a New York State Volunteer Fire Company or Department?
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Yes
No
If yes, which department or company?
Your answer
Have you ever applied for membership in the Medway-Grapeville Fire Company?
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Yes
No
If yes, when?
MM
/
DD
/
YYYY
Have you ever been convicted of a felony?
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Yes
No
If yes, please provide details.
Your answer
In the past three years, have you received any traffic violations?
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Yes
No
If yes, please provide details.
Your answer
Do you have any physical disabilities?
*
Yes
No
If yes, please explain.
Your answer
By checking this box, you affirm that the above information is true to the best of your knowledge.
*
I affirm.
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Send me a copy of my responses.
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