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| Personal Information |
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Name:
Last, First, Middle
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| List any other names you have used or been known by (include maiden name) :
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| Date of Birth:
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Address:
Number & Street, City, State, Zip
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| Home Phone Number:
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| Business Phone Number :
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| Cellular Phone Number:
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| Email Address:
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| Drivers License #:
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| Driver's License Class:
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| Are you legally able to work in the US: |
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No
Yes
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| Hours Available: Days :
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| Hours Available: Nights:
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| Have You Had EMT Training: |
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No
Yes
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| EMT Expiration Date:
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| Have You Had Paramedic Training: |
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No
Yes
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| Paramedic Expiration Date:
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| Are You a Certified Firefighter: |
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No
Yes
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| Firefighter Certification Level:
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| Are You a Certified Fire Apparatus Engineer: |
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No
Yes
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| Are You Certified in Hazardous Materials Operations Level: |
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No
Yes
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| Education |
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| Highest grade completed: |
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GED Certificate
High School
College 1
College 2
College 3
College 4
Graduate School
M.A.
Ph.D.
Other
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| Name and Address of School:
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| Date(s) Attended:
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| Did you graduate: |
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No
Yes
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| What college degrees have you attained:
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| List course work relevant to position applied for:
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| Have you ever been convicted of a crime other than minor traffic violations: |
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No
Yes
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| If "Yes for conviction," please explain:
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| Have you ever been refused a driver's license: |
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No
Yes
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| If you have you ever been refused a driver's license, please explain:
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| Has your driver's license ever been suspended or revoked: |
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No
Yes
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| If your driver's license ever been suspended or revoked, please explain:
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| Employment History |
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| List all jobs you have held for the last ten years. Include periods of unemployment. Put your present or most recent job first. Include military service in proper time sequence along with temporary or part-time jobs. |
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| Present (most recent) employer's name:
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Present (most recent) employer's address:
Number & Street, City, State, Zip
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| Job Description :
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| Supervisor's Name:
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| Supervisor's Email :
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| Do you object to our contacting them: |
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No
Yes
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| Reason for leaving :
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| Salary:
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| Paid Per:
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| Date Started Present Employer:
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| Date Ended Present Employer:
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| 2nd Employer's name :
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| 2nd Employer's address:
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| 2nd Employer's Job Description:
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| 2nd Employer's Supervisor Name:
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| 2nd Employer - Can we contact your previous employer: |
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No
Yes
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| 2nd Supervisor's Email:
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| 2nd Employer - Reason for leaving previous employer:
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| 2nd Employer - employment start date:
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| 2nd Employer - employment end date:
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| 3rd Employer's name:
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| 3rd Employer's address:
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| 3rd Employer's Job Description:
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| 3rd Employer's Supervisor Name:
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| 3rd Employer - Can we contact your previous employer: |
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No
Yes
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| 3rd Supervisor's Email:
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| 3rd Employer - Reason for leaving previous employer:
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| 3rd Employer - employment start date:
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| 3rd Employer - employment end date:
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| 4th Employer's name:
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| 4th Employer's address:
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| 4th Employer's Job Description:
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| 4th Employer's Supervisor Name:
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| 4th Employer - Can we contact your previous employer: |
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No
yes
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| 4th Supervisor's Email:
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| 4th Employer - Reason for leaving previous employer:
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| 4th Employer - employment start date:
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| 4th Employer - employment end date:
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| Have you ever been suspended or terminated, other than from an economic layoff, from any prior employment: |
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No
Yes
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| If you have been suspended or terminated from any prior employment, please explain:
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| Have you ever resigned from any employment position because of misconduct or unsatisfactory performance or while under investigation: |
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No
Yes
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| If you have resigned from any employment position because of misconduct or unsatisfactory performance or while under investigation, please explain:
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| Are you currently on any fire department eligibility list(s): |
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No
Yes
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| If you are currently on any fire department eligibility list(s) , indicate position applied for, status on list and expiration date of each:
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| References |
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| Please list three adults not related to you and not former employers, who have known you for more than three years. All persons to whom you refer will be asked to appraise your character, ability, experience, personality, and other qualities. |
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| Reference #1 Name:
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| Reference #1 Email Address:
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| Reference #1 Cell Phone Number:
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| Reference #1 Business Phone:
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| Reference #1 Occupation:
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| Reference #1 Relationship:
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| Reference #2 Name:
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| Reference #2 Email:
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| Reference #2 Cell Phone:
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| Reference #2 Business Phone:
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| Reference #2 Occupation:
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| Reference #2 Relationship:
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| Reference #3 Name:
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| Reference #3 Email:
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| Reference #3 Cell Phone:
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| Reference #3 Business Phone:
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| Reference #3 Occupation:
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| Reference #3 Relationship:
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| List organizations of which you are a member that relate to the position that you are applying for:
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| Emergency Contacts |
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| #1 Emergency Contact Name:
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| #1 Emergency Contact Adress:
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| #1 Emergency Contact Phone:
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| #1 Emergency Contact Relationship:
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| #2 Emergency Contact Name:
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| #2 Emergency Contact Adress:
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| #2 Emergency Contact Phone:
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| #2 Emergency Contact Relationship:
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| Acknowledgments |
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| Prior to employment, all applicants must produce a valid driver's license or state identification card and one document listed below:
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A birth certificate issued by the State Department, Form FS-545
A birth certificate issued abroad by the State Department, Form DS-1350
An original or certified copy of a birth certificate issued by a state, county or municipal authority, bearing a seal
Native American tribal documents
A United States citizen identification card, INS Form I-197, or
An identification card for use of a resident citizen in the United State INS Form I-179
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| Please attach copies of all certificates related to the fire service:
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| I hereby certify that i have read the above questions and statements, and i certify that there are no willful misrepresentations, omissions, or falsification in this questionnaire, and that all my answers are true and correct to the best of my knowledge. |
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| I understand that any misrepresentations, omissions, or falsifications on this questionnaire may result in my application no longer being considered or in termination of my employment with Fox River & Countryside Fire Rescue District. |
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| Electronic Signature of Applicant:
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WE ARE AN EQUAL OPPORTUNITY EMPLOYER. This organization is committed to the policy of equal employment opportunity in recruitment, hiring, career advancement, and all other personnel practices. Your job-related experience and other qualifications will be considered without discrimination on the grounds of race, color, religion, sex, national origin, age, or physical or mental handicap. All information provided in this application will be treated confidentially and will be used only to help assure the best use of your abilities if you are employed with us.
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