Cedar Mountain Fire Rescue Auxiliary
Membership Application
Date_____________________
Full Name ________________________________________________
Address___________________________________________________________
City___________________________ State_____________ Zip Code_________
Home Phone No. ___________________Cell phone______________________
E-mail Address_________________________________
Social Security No. (department purposes)______-_____-________
(for insurance purposes)
Driver’s license No _______________________________
Birthdate:_________________________ Employed? Yes ___ No ___
Are you a part-time resident? Yes ___ No ___
Emergency Contact Information
Name ____________________________________________________________
Address __________________________________________________________
City _____________________________State____________Zip Code________
Phone Number (where contact can be reached)_______________________________
------------------------------Aux. Use---------------------------------------------------------------
First meeting attended (Date)________________________
Entered in Roster__________________________________
I.D. Card issued___________________________________