Wisconsin State Firefighters' Association, Inc.

MEMBERSHIP APPLICATION

Please print this form and mail, with $25.00 membership fee to:

Name: ________________________________________________________________________

Home Address: _________________________________________________________________

City: _________________________________________________________________________

State: ________________________________

Zip Code: _____________________________

Personal Email: _________________________

Beneficiary: ____________________________________________________________________

Phone Number: _________________________________________________________________

Birthdate: _____________________________________________________________________

Fire Department: ________________________________________________________________

Department Email: _______________________________________________________________

Wisconsin State Firefighter's Association
P.O. Box 126
Durand, WI 54736

Click here for the Provident Insurance Company Beneficiary Form

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