Date of Birth
Applying for: Career Firefighter Volunteer/Support Member Reserve Member
How long of you lived at your current address?
Social Security Number
Email
Home Phone
Cell Phone
Current Employer:
Current Employer Address:
How long have you worked for current employer?
Current Employer Phone Number:
Fax:
Previous Employer?
Date Started:
Date Ended:
Reason for leaving?
Emergency Contact Phone
Relationship to Contact
Have you ever been counseled, disciplined, terminated or asked to resign as a result of reported workplace harassment, fighting/assault, violation of safety rules, or other inappropriate conditions: NO YES, (Explain) Have you ever been counseled, disciplined, terminated or asked to resign as a result of reported workplace harassment, fighting/assault, violation of safety rules, or other inappropriate conditions:
This department is an equal opportunity department. As such, we provide all opportunities without regards to race, color, religion, national origin, age, disability, veteran status, military service, or other characteristics protected by law. I certify that the information provided on this application form along with all other information I have provided to the department, is accurate and complete. I understand that any misrepresentations or omissions will be cause for not being considered for employment or for terminating my employment once accepted. I understand that The Department will undertake, and I authorize the department to undertake, any investigation it deems necessary in considering me for membership. I expressly authorize any present or former employer; school, college, or university; utility company; credit or finance bureau; personal reference; chief law enforcement officer; any member of any local, state, or federal law enforcement agency; or any other person to give the department any information (written or oral) or records concerning me or my qualifications, employment (including but not limited to the reasons for my termination), credit, reputation, mode of living, education, or criminal record. I unconditionally release the department and its representatives and agents and all persons from whom they request information from any and all liability relating to such request for information or any information provided. I understand that this application will be for employment only and only during the period the department is seeking to fill the current opening(s), and that employment may be conditioned upon a medical examination and/or drug testing and/or criminal history check. I understand that, if accepted, my employment will be strictly at-will. That means that my employment can be terminated by The Department or I may terminate the employment at any time, for any or no reason, with or without notice or intermediate steps. I further understand that no verbal statements or statements in any department policy or procedure manual, handbook, or other document shall be construed to have altered the at will nature of my employment. The administration of this fire department wants you to understand that providing fire protection and being a firefighter is a very dangerous job. The fire/rescue service losses approximately 100 fire/rescue members per year protecting the citizens of the United State. I Understand/Agree I Do NOT Understand/Disagree
If you are human, leave this field blank.
