CONNECTICUT
STATE FIREFIGHTERS ASSOCIATION, INC.
POST OFFICE BOX 9
PHONE: (860)
423-5799; FAX: 860-423-5799
APPLICATION FOR MEMBERSHIP
DATE:
_________________
COMPANY
APPLICATION: ____
DEPARTMENT
MEMBER APPLICATION: ____
POSITION
IN DEPARTMENT: __________________________________________________
NAME:
______________________________________________________________________
ADDRESS:
___________________________________________________________________
CITY/TOWN: _____________________________COUNTY:
_____________ZIP: __________
TELEPHONE
_____________________________FAX: _______________________________
SIGNATURE OF CHIEF OF DEPARTMENT. ______________________________________
NAME OF
FIRE DEPARTMENT AFFILIATION: ____________________________________
A check
for $65.00 must accompany a Company Member application.
A check
for $20.00 must accompany a Department Member application.
=====================================================================
CSFA
OFFICE USE ONLY:
Membership
Number: ____________________
Executive
Committee Vote: _______________
Recorded
to file: ___________________________