Internal Employment Application

Position Applying For (Use Specific Title) (required)

Date (mm/dd/yyyy) (required)

First Name (required)

Last Name (required)

Email (required)

Phone (required)

Physical Address

Street Address 1 (required)

Street Address 2

City (required)

State (required)

Zip (required)

Mailing Address, same as physical? (required)

Yes

If You selected no, please fill out your address below.

Street Address 1

Street Address 2

City

State

Zip

Are you 21 or older? (required)

Yes

Are you legally eligible for employment in the United States? (If offered employment, you will be required to provide documentation to verify eligibility.) (required)

Yes

Employment History

Include your last ten (10) years of employment history or last four (4) employers, including periods of unemployment (please do not include any medical information), starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration. You will have a chance to attach and upload your resume at the end of this form.

Employer Name (1)

Address

Position

Start of Employment

End of Employment

Supervisor Name

Supervisor Title

Supervisor Phone

Description of Duties

Reason for Leaving

Employer Name (2)

Address

Position

Start of Employment

End of Employment

Supervisor Name

Supervisor Title

Supervisor Phone

Description of Duties

Reason for Leaving

Employer Name (3)

Address

Position

Start of Employment

End of Employment

Supervisor Name

Supervisor Title

Description of Duties

Reason for Leaving

Employer Name (4)

Address

Position

Start of Employment

End of Employment

Supervisor Name

Description of Duties

Reason for Leaving

If presently employed, may we contact your employer?

Yes

FIRST RESPONDERS ONLY

Relevant Fire and EMS Experience Answer only the specific inquiries below which are relevant to the position for which you are applying. Feel free to supplement your answers with a resume and/or other pertinent documents.

Level of Emergency Medical Technician Training:

Basic

Intermediate

Paramedic

Date of Expiration

Attach Certificate

Level of structural firefighting training:

Firefighter I

Firefighter II

Fire Officer I

Other

If Other:

Date of Expiration

Attach Certificate

Have you completed hazardous materials training?

Yes

Please list any licenses or certifications that you hold which would be useful in this position:

Describe nature and extent of fire experience:

Describe nature and extent of emergency medical experience:

Describe nature and extent of leadership experience:

Describe your volunteer responder experience:

NON-RESPONDERS

Please list any licenses or certifications that you hold which would useful in this position:

Describe the office equipment and computer programs that you are familiar with:

Describe any other skills or experience you have which you feel is relevant to the position for which you are applying:

EDUCATION

High School

High School Name

High School Location

Graduated High School?

Yes

College/University

College/University Name

College/University Location

College/University Degree/Certificate

College/University Graduated?

Yes

Vocational/Technical

Vocational/Technical Name

Vocational/Technical Location

Vocational/Technical Degree/Certificate

Graduated? Vocational/Technical

Yes

PROFESSIONAL LICENSES OR MEMBERSHIPS

You need not disclose memberships in professional organizations that may reveal information regarding Race, Color, Creed, Religion, Gender, Age, Marital Status, National Origin, Ancestry, Citizenship status, Physical or Mental Disability, Sexual Orientation, Genetic information, Physical and Mental Disability or any other status that is protected by state or federal law.

License Type

License Number

Expiration Date

License Type

License Number

Expiration Date

Additional Licenses

PERSONAL REFERENCES

Supply the names of individuals who can give the Authority information regarding your work character, abilities, and experience.

Reference 1 Name

Reference 1 Phone

Reference 1 Email

Reference 1 Relationship

Reference 1 Years Acquainted

Reference 2 Name

Reference 2 Phone

Reference 2 Email

Reference 2 Relationship

Reference 2 Years Aquainted

Reference 3 Name

Reference 3 Phone

Reference 3 Email

Reference 3 Relationship

Reference 3 Years Acquainted

ADDITIONAL INFORMATION

This space allows for any information that you may not have had the opportunity to enter above.

Upload resume, cover letter, any additional documentation

AFFIDAVIT: Please read each statement carefully before signing. The information contained in this application and supporting employment documents is true to the best of my knowledge and belief. I understand and agree that, if in the opinion of the Authority, I have made any misrepresentations or false statements in connection with the application and supporting employment documents, the Authority may reject my application or, dismissal at any time if employed. I understand that all information furnished in this application and supporting employment documents may be verified. I hereby authorize all individuals and organizations named and referred to in this application and supporting employment documents and any laws enforcement organization to release any and all information relative to such verification and hereby release such individuals, organizations and the Authority from any and all liability for any claim or damage resulting there from. I understand that, following an offer of employment, employment may will be contingent upon successfully completing a, background check, drug screen, medical physical, fitness testing and functional movement test. I consent to the release of any or all personal and/or professional and/or medical information as may be deemed necessary to judge my capability to do the work for which I am applying. In accordance with the Immigration Reform and Control Act of 1986, I understand that I will be required to provide documentation as to my identity and authorization to work in the U.S. should employment be offered to me. I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice. I state that I have made no willfully false or misleading statements in this application or otherwise and that I will make no willfully false or misleading statements about my ability to perform if I am selected to continue in the interview/selection process. This application will remain active no more than six (6) months from the date it was submitted. I understand that should I be offered employment, it may be conditional upon the contents of my driving record as provided by the Department of Motor Vehicles.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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