PROVIDENCE CITYWIDE FIRE NETWORK
APPLICATION FORM

NAME:_______________________ HOME# ( ) ______________ WORK# ( ) _______________

STREET__________________________________________________________________

CITY: _______________________ STATE ________________ ZIP __________________

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.

SIGNATURE OF APPLICANT:_________________________________ DATE:__________________

ACTION OF MEMBERSHIP COMMITTEE: ______________________________________________

CAR# ASSIGNED: __________________ DATE ACTIVATED: ______________________________

ALPHA NUMERIC PAGER: YES_______ NO ________ PAGER NUMBER: ____________________

PLEASE 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