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REQUEST FOR 50/100 YEAR CERTIFICATES
Date Submitted: __________________
Name of Candidate: ________________________________________________________________
Address of Candidate: ______________________________________________________________
________________________________________________________________________________
Date Joined/Started:_______________
Name of submitting Fire Dept/Company: ________________________________________________
Name of submitting Fire Dept/Company Officer: __________________________________________
Address: _________________________________________________________________________
________________________________________________________________________________
Phone # / Email address:________________________/____________________________________
ANY INFORMATION TO SUPPORT THE CERTIFICATE
____________________________________________________________________________.
____________________________________________________________________________.
____________________________________________________________________________.
____________________________________________________________________________.
____________________________________________________________________________.
____________________________________________________________________________.
____________________________________________________________________________.
All request should be forwarded to:
Secretary Michelle Effland, PO Box 544, Oriskany, NY 13424
ocvfa.secretary@gmail.com
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