Application For Employment

Transcription

1 Application For Employment Pro-Tec Fire Services, Ltd South Oneida Street Green Bay, WI Phone (920) Fax (920) We do not discriminate on the basis of race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legally protected status. Please Print Location you are applying for: Date: Position(s) Applied For and Location: Fire Chief Deputy Chief Assistant Chief Captain Lieutenant Firefighter Last Name First Name Full Middle Name Address Street City State Zip Code Telephone Number(s) Cell Phone Number Address Have you ever been employed with us before? (Dates) Are you at least 18 years of age? (21 years of age - Burbank, California and Medford, Oregon) Are you currently employed? May we contact your present employer? Are you legally authorized to work in the United States? On what date are you available for work? Salary Desired: Are you available to work: Full Time Part Time Will you work additional time during the week if necessary? Can you travel if the job requires it? Have you ever been convicted of a crime, either misdemeanor or felony, including ordinance and traffic violations? NOTE: A conviction record or pending arrest record does not constitute an automatic bar to employment and will be considered only if there is a substantial relationship to the circumstances of the particular position or if there is a bona fide occupational qualification inherent in the position which requires this information prior to hiring. If yes, explain below: Incident City/State Charge JJ 101 (revised 11/16/2011) WE ARE AN EQUAL OPPORTUNITY EMPLOYER

2 APPLICATION FOR EMPLOYMENT (Continued) Page 2 Education Name and Address of School Course of Study Years Completed Diploma Degree High School College Other Employment Experience Begin with your most recent job and list all employers for the last seven (7) years. Include part-time, full-time and all periods of employment. If there are gaps in time between jobs (receiving unemployment, illness, etc.) use one section below to explain each gap. 1. Supervisor s Name Telephone Number(s) 2. Supervisor s Name: Telephone Number(s)

3 APPLICATION FOR EMPLOYMENT (Continued) Page 3 3. Supervisor s Name Telephone Number Include only reference familiar with your work capabilities. References: Specialized Skills Indicate the number of years in the space provided that is applicable to Skills/Experience, Certifications, Licenses, Equipment Operated: ARFF Exp. Structural FF Exp. HAZMAT Cert. # of Years FF Certifications # of Years # of Years Military FF 1 No. of Years Awareness Civilian FF 2 Paid Dept. Operational No. of Years Airport FF Volunteer Dept. Technician Fire Officer 1 Other List below Instructor Other List below Rescue Exp. EMS # of Years # of Years Miscellaneous Jaws 1 st Responder Valid Driver s License Yes No High Angle CPR Class B Driver s License Yes No Water EMT -B Inoculation Hepatitis B Yes No Confined Space EMT- P Other Hep B Vaccination Date APPLICATION FOR EMPLOYMENT (Continued) Page 4

4 List Other Qualifications You Feel Are Relevant The Job For Which You Are Applying: Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? YES NO DISCLOSURE & RELEASE AUTHORIZATION In connection with my application for (or the continuation of my) employment with you, I understand that you may be requesting information concerning my driving record, credit history, criminal history, educational history, professional licensure and certification, workers' compensation claims, and/or other records available from various state, private, and insurance sources. I further understand that the information being sought may come within the definitions of a "Consumer Report" as set forth in the Fair Credit Reporting Act. Workers' compensation information will only be requested in compliance with the ADA. I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY LAW ENFORCEMENT AGENCY, ADMINISTRATOR, STATE AGENCY, INSTITUTION, INFORMATION SERVICE BUREAU, EDUCATIONAL INSTITUTION, EMPLOYER OR INSURANCE COMPANY TO FURNISH THE ABOVE-MENTIONED INFORMATION, AND AGREE TO RELEASE THEM FROM ANY LIABILITY FOR ANY DAMAGE WHATSOEVER FOR ISSUING SUCH INFORMATION. I further acknowledge that copies of this form (e.g., faxed, scanned, photocopied, etc. shall be as valid as the original. This release includes all state and federal agencies including State Department of Labor. Last Name First Name Middle Initial Other Name I am/have been known by Address Street City State Zip Code Other Cities/States in which I have lived Driver s License Number State in which driver s license was issued Date of Birth I would like to receive a copy of the Consumer Report. You may be entitled to receive additional information regarding the nature and scope of this report from the Consumer Reporting Agency. (This option may not be available in all states). FOR EMPLOYER USE ONLY

5 APPLICATION FOR EMPLOYMENT (Continued) Page 5 CERTIFICATION I certify the answers given by me to the foregoing questions and any statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentations of facts regarding information called for in this application may result in rejection of my application, or discharge at any time during my employment. I also agree that, if company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that if I am hired, my employment shall be "at-will," and that either the Company or I can choose to terminate the employment relationship for any reason, or no reason at all, with or without notice. AUTHORIZATION I understand that background, drug or medical testing may be conducted on me as part of the process to determine my fitness for employment, and hereby agree to submit to such testing. I authorize all persons, schools, companies, medical practitioners, current and/or former employers, and law enforcement authorities to release any information concerning my background or test results, and hereby release any 1 said persons, schools, companies, medical practitioners, current and/or former employers, and law enforcement from any liability for any damage whatsoever for issuing this information. I hereby understand that I may be required to submit a medical examination if offered a position conditioned on such examination. I also understand that I may be required to submit to testing for controlled substances or other drugs. I have read (or have had read to me), understand and agree to the above statement. (Please initial here) Applicant's Full Name (printed): Signature: Date: Revised 11/16/2011