Somers Exempt Volunteer Firemens Benevolent Association

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Application

Required   Indicates Required Field
Last Name: Required
First Name: Required
Middle Initial:
Home address street: Required
Home address apt:
Home address town: Required
Home address state: Required
Home address zip: Required
Mailing address (if different from home address)
Mailing address street:
Mailing address apt:
Mailing address town:
Mailing address state:
Mailing address zip:
Additional member details
Cellphone:
Landline:
Email: Required
Sex: Required M
F
Date of birth: Required
Date joined the SVFD: Required
Spouse name:
Spouse phone number:
Beneficiary information
Beneficiary full name: Required
Beneficiary address street: Required
Beneficiary address apt:
Beneficiary address town: Required
Beneficiary address state: Required
Beneficiary address zip: Required
Beneficiary phone: Required
Share %: Required
Additional beneficiaries?:
If you wish additional beneficiaries, provide beneficiary address, phone and percentage allocation. Percentage must not exceed 100%
Timestamp: Required 04/07/2025 0450




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Benevolent Association, Inc.
P.O. Box 235
Lincolndale, NY 10540		 E-mail: webmaster@svfdbenevolent.org
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