PROVIDENCE CITYWIDE FIRE NETWORK
APPLICATION FORM

PLEASE FILL OUT THIS FORM AND SUBMIT TO GET YOUR APPLICATION PROCESS STARTED. YOU WILL STILL NEED TO SEND IN THE APPLICATION FEE ($12.00) WITH MEMBERSHIP FEE ($80.00) OR ASSOCIATE MEMBERSHIP FEE ($20.00) BEFORE FINAL APPROVAL OF MEMBERSHIP.

NAME: HOME# WORK#

ADDRESS

CITY:STATEZIP

OCCUPATION:

A. CHARACTER REFERENCES:

NAME: PHONE#

NAME:PHONE#

B. SPONSORING MEMBER: PCFN CAR #:

C. FIRE LINE PASS OR DEPARTMENT BADGE: YES: NO:

IF YES, BY WHOM:

D. APPLICATION AND MEMBERSHIP FEES:

1. APPLICATION FEE IS $12.00 (NON-REFUNDABLE)

2. MEMBERSHIP FEE: $80.00 ANNUALLY (PAID IN FEBRUARY)

3. ASSOCIATE MEMBERSHIP: $20.00 ANNUALLY. THIS MEMBERSHIP WILL RECEIVE COPY OF NEWSLETTER, AND BE ENTITLED TO ATTEND MEMBERSHIP DINNERS AND MEETINGS.

NOTE: NO RADIO RIGHTS OR VOTING POWERS ALLOWED WITH ASSOCIATE MEMBERSHIPS.

                                           BY TYPING YOUR NAME BELOW IT IS AN ACT OF A SIGNATURE. 

SIGNATURE OF APPLICANT: DATE:

ACTION OF MEMBERSHIP COMMITTEE: ______________________________________________

CAR# ASSIGNED: __________________ DATE ACTIVATED: ______________________________

ALPHA NUMERIC PAGER: YES_______ NO ________ PAGER NUMBER: ____________________

YOU CAN PRINT OUT THIS FORM
MAKE CHECK OR MONEY ORDER PAYABLE TO PROVIDENCE CITYWIDE FIRE NETWORK
MAIL TO: PCFN/ PO BOX 41242, PROVIDENCE RI., 02940
THERE WILL BE A $20.00 FEE FOR ALL RETURNED CHECKS