Membership Application - Hershey Volunteer Fire Department

Thank you for your interest in joining Hershey Volunteer Fire Department. Please complete the membership application form below.

Once submitted, a member of our Membership Committee will review your application and contact you for further steps.

Indicates Required Field

Position Applying For Required

Fire Crew Fire Police Support Member

General Information

First Name Required

Legal First Name

Last Name

Legal Last Name

Social Security Number

Birth Date Required

Middle Initial Required

Legal Middle Initial

Drivers License Number Required

State of License Required

Address

Street Address, City, State / Province, Zip Code

E-mail Address Required

Phone Number Required

Alternate Phone Number

Current Employer Required

Employer Info (Current) Required

Name, Address Phone Number

Can you leave work for Fire Calls Required

No Yes

Name of Supervisor Required

Normal Work Schedule Required

Emergency Contact Name Required

Emergency Contact Phone Number Required

Education History

Do you have either a High School Diploma or GED Required

No yes

School or Training Required

Please include any colleges or any other schools attended.

Special Qualifications

Licenses, skills with machines, other Fire Department memberships or related archives

Work History

1. Name of Employer

1. Address

1. Supervisor Phone Number

1. Job / Duties Performed

1. Reason for Leaving

2. Name of Employer

2. Address

2. Supervisor Phone Number

2. Job / Duties Performed

2. Reason for Leaving

3. Name of Employer

3. Address

3. Supervisor Phone Number

3. Job / Duties Performed

3. Reason for Leaving

Prior Residences

Address 1

Street Address, City, State / Province, Zip Code

Address 2

Street Address, City, State / Province, Zip Code

Address 3

Street Address, City, State / Province, Zip Code

References

Please list three persons who are not related to you and who have definite knowledge of your qualifications or fitness for membership. Do not use names of supervisors you listed above as we consider them references, unless otherwise noted.

1. Full Name Required

1. Phone Number

2. Full Name Required

2. Phone Number Required

3. Full Name Required

3. Phone Number Required

Criminal History

Have you ever been convicted of a crime? Please include any misdemeanor or felony convictions Required

No Yes

If yes, list date of offense, all charges for which you were convicted and the disposition

Medications

Do you have any medical conditions or medications that would prevent you from your duties for the position you are applying for Required

No Yes

Authorization for Release of Information

Enter your full name which signifies your understanding and approval of the above statement Required

Submitted on Required

10/17/2026 0759

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I authorize the Hersey Volunteer Fire Company to conduct an investigation into my background, including but not limited to anyrecord of Criminal Arrests which may exist, and to the release to the Hershey Volunteer Fire Companyany and all information obtained as a result of such investigation.

I further understand that this investigation will be confidential and findings contrary to theinformation provided on the application may subject me to prosecution under the Pennsylvania crimescode for unsworn falsifications (18 PA. C.S. §4904). I understand that the information will be released tothe appropriate officers of the Hershey Volunteer Fire Company when the investigation is completed.
I verify that the information setforth in this application is true and correct. I understand that any falsification contained in this application shallresult in denial or termination of membership. This verification is made subject to the penalties ofsection 4904 of the crimes code of Pennsylvania(18 PA. C.S. §4904) Relating to unsworn falsifications.