Members of our fund must be members of a fire department in the State of Washington.  Below is an application form to be used by individuals that have NOT reached their 45th birthday.  If you have reached or passed your 45th birthday, please contact the treasurer (see "CONTACT" above) for information.

                       SPOUSE AND ORPHANS’ FUND APPLICATION FORM
                        PO Box 27 Sumner WA 98390-0027 Phone: 253-445-9624

I hereby make application for membership in the Washington State Firefighter’s Spouse

and Orphans’ Fund. I certify that I have not reached my 45th birthday. I am in general

good health and know of no reason that would prevent me from being accepted by an

insurance company. I agree to abide by the Constitution and By-Laws now existing or

as may hereafter be changed, altered or amended. I herewith subscribe to the Spouse

and Orphans’ fund, enclosing a remittance of $52.00 to pay the assessment for the

fiscal year ending on June 30.

Full Name_______________________________________________________________________
(Print) First Middle Last

Address_________________________________________________________________________

City ___________________________________________ State _______ Zip _________________

Age ____ Born at _________________________ Month __________Day_________ Year_______

Beneficiary (limited to SPOUSE, PARENTS, CHILD, ESTATE,  LIVING TRUST or registered

WASHNGTON STATE DOMESTIC PARTNER)

Name of beneficiary ______________________________________________________________

Relationship (see above) ___________________________________________________________

Address ________________________________________________________________________

City __________________________________ State _________ Zip _______________________

Dated at ___________________________ this __________ day of ___________, 20__________


X_____________________________________________________________________________
Signature of Applicant

X_____________________________________________________________________________
Witness

Approved by fire department (Two signatures please)


X _____________________________________ X _____________________________________


Fire Department Name____________________________________________________________

For office use only: ID ____________ Payment # ___________
Rev for use 7/01/2011
(Web)