Membership Application for Station 1 (18+)
I, ______________________________________________________________________
Date of Birth:__________________________ Driver’s License:____________________
Social Security:_____--_____--_____ Phone:_____________ Cell:_________________
Home address: ___________________________________________________________
Street Town State Zip
Do hereby release the Union Fire District and/or the South Kingstown Police Department and its officers, agents, employees from any liability resulting from an investigative background check for the position as volunteer with the Union Fire District.
And further, I _________________________________ do hereby release all manner of claims and demands, both in law and equity, more especially any and all claims relating to the background investigation conducted by the Union Fire District for the position with the Union Fire District.
In witness whereof, the said __________________________________________ has caused these presents to be signed, acknowledged and delivered in his/her name on this_________ day of ___________.
By:_______________________________________
Signature
Notary:
State of Rhode Island County of ________________________________________
In ____________________________, in the said County on the _____________ day of
___________, 20___ before me personally appeared _____________________ each and all to me known, and known by me to be the party executing the foregoing instrument and he/she acknowledged said instrument to be his/her free act and deed.
Notary:___________________________________
Commission expires: ________________________
SKPD approved______ denied_______ by:____________________________________
