INDIANA VOLUNTEER FIREFIGHTER’S ASSOCIATION – MEMBERSHIP ENROLLMENT FORM

CHECK ONE BOX ÿ New Member ÿ Beneficiary Change ÿ Miscellaneous Changes ÿ Transfer From Another Dept. Old Department____________________________________________________ City ________________________ New Department___________________________________________________ City _______________________ _

CHECK ONE MEMBER DESIRED BOX ÿ Active ÿ Armed Services ÿ Inactive ÿ IVFA Past President ÿ Industrial ÿ 50 yr. Life Member ÿ Associate

Complete all items / please print or type clearly!

Department Information

IVFA Department # District # PR Area # County/Department # -

Department Name City

Member Information

Members Name , ,

Last Name First Middle

Mailing Address

City State Zip County

Telephone / Social Security # - - Date Entered Fire Service

Beneficiary Information

MULTIPLE BENEFICIARIES WILL BE DIVIDED EQUALLY (no exceptions)

Name Relationship

Name Relationship

Name Relationship

Name Relationship

Signature Date / /

Revised 2/14/02