Membership Application

Membership Application

West Lake Fire Department - 3762 West Lake Road, Erie, PA 16505 (814) 833-4115
Applying for Position *
Please select one
Full Name *

First Name Middle Name Last Name
Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Phone Number *

Area Code Phone Number
Email Address *
Social Security Number
xxx-xx-xxxx
Education
High School
School name, Address, Graduation Date, Diploma
College/University
School name, Address, Graduation Date, Diploma
Are you a U.S. Citizen?

Yes No
Have you ever been a member of this department?

Yes No
Have you ever been convicted of a felony?

Yes No
If yes, please explain
Drivers License Number, Issuing State and Expiration
Emergency Contact
Certification and Experience
Do you have any medical training? If yes, please provide the type and date of certification/expiration.
Ex: EMT-B, CPR, First Aid
Do you have any firefighting/rescue training? If yes, please provide the type and date of certification/expiration.
Ex: Firefighter 1, Water Rescue, Hazmat
Military Service: Please list branch, discharge type and dates served.
Please list any West Lake member that you know.
Previous Fire Department Affiliation (provide address, phone number and supervisor).
Please list any fire department you have belonged to

Education