Suffolk County Volunteer Firefighters Emerald Society

                                   MEMBERSHIP APPLICATION
 

INSTRUCTIONS:     MEMBERSHIP IS OPEN TO MEMBERS OF ANY SUFFOLK COUNTY NY VOLUNTEER
FIRE DEPARTMENT OR VOLUNTEER AMBULANCE COMPANY.

COMPLETE THIS ON-LINE APPLICATION, PRINT IT OUT AND BRING IT WITH YOU, ALONG WITH A
$20.00 CHECK FOR DUES, TO THE NEXT MEETING OF THE SOCIETY LISTED ON THE EVENTS PAGE.

NAME:              

MAILING ADDRESS:           

CITY:          NY         ZIP:

HOME PHONE:     CELL PHONE:  E-MAIL:

NAME OF FIRE DEPT OR AMBULANCE COMPANY:

DEPARTMENT ADDRESS:

LENGTH OF SERVICE:

CHECK HERE IF YOU WILL BE PAYING YOUR DUES 
CHECK HERE IF YOUR DEPARTMENT WILL BE PAYING YOUR DUES 

TO WHAT DO YOU ATTRIBUTE YOUR IRISH LINEAGE ?

SIGNATURE: _____________________________________________        TODAY'S DATE: