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Office for Volunteer Fire l licemen
York State Municipal Law, Sectlon~J~-C.)
STATE OF NEW YORK
SUFFOLK COUNTY
TOWN OF SOUTHOLD
I, . ............ ..~.~.~..?..e.....R..e:..~.~.e. ..................................... , do solemnly swear (or affirm)
/Type or 'Print Name)
that I will support the Constitution of the United States, and the Constitution of the State
of New York, and that I will faithfully discharge the duties of the office of Fire Policeman
of the ................. ..~.~.t;...~.~..~..q.¥. ..................... Fire Deportment, according to the best of
my ability.
Signature ...~..~........~.'.......~...~... · ........................
Sworn to before me, this ../...~. ...... day
of~~ ........... , 19.-~. --~--.
~ GENEVIEVE E. HARRIS
Notary Public, State of New York
No. 62 - e78o~6o,
Original to be filed with Town (Village) Clerk.
Copy to be held by Department .Secretary.