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Employment Application

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Application For Employment

Last Name
First Name
Middle Name
Address
Phone Number
Position Applying for
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How did you hear about us?
* Have you ever filed an application with us before? Have you ever filed an application with us before?
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* Have you ever been employed with us before? Have you ever been employed with us before?
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* If hired, are you willing to work overtime? If hired, are you willing to work overtime?
Are you currently employed? Are you currently employed?
* May we contact your present employer? May we contact your present employer?
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* Do you have a valid driver’s license? Do you have a valid driver’s license?
State
* Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
* Can you provide required proof of your eligibility to work? Can you provide required proof of your eligibility to work?
* Are you physically or otherwise unable to perform the duties of the job for which you are applying? Are you physically or otherwise unable to perform the duties of the job for which you are applying?
* Have you ever been discharged from a job? Have you ever been discharged from a job?
If Yes, please explain:

The Deer Park Silverton Joint Fire District will not discriminate against any employee or applicant for
employment because of age, religion, gender, race, sex, pregnancy, color, national origin, disability, military status, veteran status, or any other legally protected status. Employment decisions will be based upon skills, abilities, or other job-related criteria only.

Education

High School

School Name
School Address
Years Completed
Diploma/Degree

College

School Name
School Address
Years Completed
Diploma/Degree

Other (Specify)

School Name
School Address
Years Completed
Diploma/Degree

Fire and EMS Related Training

Please Attach Copies of Certification Cards to Application

EMT

Year Completed:
Certification Number:
Institution/ Location:

Paramedic

Year Completed:
Certification Number:
Institution/ Location:

Firefighter

Level:
Year Completed:
Certification Number:
Institution/ Location:

HazMat

Level:
Year Completed:
Institution/ Location:
Describe any other specialized training or qualifications you have relating to the position applied for
Describe any computer skills you possess, including software and hardware experience
Indicate any foreign languages (including American Sigh Language) you can speak, read and/or write

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.

Employer
Address
Phone Number
Job Title
Supervisor
Reason For Leaving
Dates Employed From/From
Describe Work Performed
* May We Contact? May We Contact?

References

Give name, address and telephone number of three references to whom you are not related.

Name
Address
Phone
Name
Address
Phone
Name
Address
Phone

The Deer Park Silverton Joint Fire District will not discriminate against any employee or applicant for employment because of age, religion, gender, race, sex, pregnancy, color, national origin, disability, military status, veteran status, or any other legally protected status. Employment decisions will be based upon skills, abilities, or other job related criteria only.

In Case of Emergency, Notify:

Name:
Address:
Phone:
Relationship:

Applicant’s Statement

1. I certify that the facts contained in this application are true and complete to the best of my knowledge. I hereby authorize you to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process. I release all parties from any liability in connection with the provision and use of such information.


2. I understand and agree that any falsification, misrepresentation, or omission either on the employment application form or in my responses to questions asked during the interview or examination process may disqualify me from further consideration for employment, or if employed, will subject me to immediate termination whenever the falsification, misrepresentation, or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope.


3. I understand and agree that, if employed by this organization; I will abide by its rule and regulations which I understand are subject to change.


4. I understand that a physical examination and a chemical test for the presence of illegal and controlled substances may be required before the commencement of and/or during my employment. I release Sycamore Township Department, their authorized agents, and their employees, and all other persons, companies, and other entities from any and all liability arising out of any physical examination or chemical testing or for the taking of any action based on the results of any physical examination or chemical testing.

Signature of Applicant
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Investigation Authorization

I understand that as a condition of my employment I will be required to produce a local criminal background check and a copy of my driving record from my insurance company. I also understand that I will be required to take a drug and alcohol test prior to my employment.

Signature of Applicant
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EMPLOYMENT APPLICATION ADDENDUM PLEASE ANSWER THE FOLLOWING QUESTIONS:

Have you had a TB test within the last year?
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Have you received a complete series of Hepatitis-B vaccinations?

If Yes, You Will Need to Provide Proof and Dates When Hired

PLEASE ATTACH THE FOLLOWING DOCUMENTS/INFORMATION TO THIS FORM WHEN RETURNING YOUR APPLICATION

Copies of the following items:
• Driver’s License
• Social Security Card
• Ohio Firefighter Certification Card
• Ohio EMS Certification Card
• ACLS Card
• Specialty Cards (i.e., PALS, BTLS, Fire Safety Inspector. etc.)
• HazMat certifications

We may contact you by email with some standard questions. Please provide us with your email address. This will speed up the process considerably. 

Email
Name
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