Part Time Fire Application

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First Name: *
Middle Initial:
Last Name: *
Suffix (Jr., Sr., etc):
Address: *
City: *
State: *
Zip Code: *
Primary Phone #: *
Secondary Phone #:
Applicant Shirt Size: *
Pant Size: *
Have you ever been convicted of domestic violence? *
Are you a US citizen? *
Are you at least 18 years of age? *
Did you ever serve in the armed forces? *
Honorable discharge? *
Have you ever been employed with us before? *
If Yes give dates;
Do any of your friends, relatives or spouse work here? *
Are you currently employed? *
May we contact your present employer? *
How did you learn about us? *
Education:
Highschool (Name/Location):
Type of Degree:
Did you graduate?
Technical School (Name/Location):
Type of Degree:
Did you graduate?
Undergraduate School: (Name/Location):
Type of Degree:
Did you graduate?
Graduate School (Name/Location):
Type of Degree:
Did you graduate?
Attending School now:
Type of Degree:
Did you graduate?
EMT/Paramedic
Type of Degree:
Did you graduate?
Firefighter 240:
Type of Degree:
Did you graduate?
General
Please list any special skills or abilities that you have: *
Please list any applicable certificates or specialized training that you have: *
Do you have a valid Ohio Driver’s License which is not suspended or has been revoked? *
If yes, please list date of violation(s) and number of points.
Please list any extra-curricular activities. *
Are you dependent on drugs, alcohol or prescription medications? *
Please list any trade, professional, business or civic activities and or offices held. *
WORK EXPERIENCE (List in chronological order starting with most current)
Most Recent Employer: *
Address: *
Phone Numbers: *
Dates Employed From - To: *
Job Title, Work Performed and Responsibilities: *
Promotions:
Supervisor’s Name: *
May we contact? *
Why did you leave? *
Previous Employer:
Address:
Phone Number:
Dates Employed From - To:
Job Title and Responsibilities:
Promotions:
Supervisor’s Name:
May we contact?
Why did you leave?
Previous Employer:
Address:
Phone Number:
Dates Employed From - To:
Job Title and Responsibilities:
Promotions:
Supervisor’s Name:
May we contact?
Why did you leave?
BACKGROUND INFORMATION
Have you ever been convicted of a felony? *
If yes, please explain:
Have you ever been convicted of any crimes in the last 5 years other than traffic violations? *
If yes, please explain:
Are you presently under indictment or are you currently a defendant in any criminal proceedings? *
If yes, please explain:
Date of indictment or pending charge:
Location of indictment or pending charge:
(Note:The employer will only consider specific crimes related to the position applied for)
REFERENCES
Reference #1:
Name: *
Address: *
Business: *
Phone Number: *
Relationship: *
Reference #2
Name: *
Address: *
Business: *
Phone Number: *
Relationship: *
Reference #3
Name: *
Address: *
Business: *
Phone Number: *
Relationship: *
PHYSICAL RECORD
Do you have any physical or medical conditions that would precluse you from performing any work for which you are being considered? *
If yes, please describe:
RESPONSIBILITY/UNDERSTANDING PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. PLEASE INDICATE YOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH PARAGRAPH. IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE CHIEF BEFORE INITIALING THE PARAGRAPH. It is fundamental policy of Scioto Township to provide equal opportunity in all of its operations and in all areas of employment practice and to ensure that there shall be no unlawful discrimination against any employee or applicant for employment on the grounds of race, color, religion, sex, national origin, age, or handicap. We request that any resume’ or information submitted not include information indicative of race, color, religion, sex, national origin, or age.
1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug and/or alcohol testing.
Initials: *
2. I have been given, read and understand the firefighter job description. I believe that I am capable of performing in a reasonable manner and with or without reasonable accommodations, the activities and duties described in the firefighter job description.
Initials: *
3. I have been given, read and understand the firefighter ethics policy. My character meets or exceeds the ethical requirements of the Scioto Township Fire Department.
Initials: *
4. I understand and accept that any information required in this application is found to be falsified or intentionally excluded; my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including dismissal, if any information required by this application has been falsified or intentionally excluded.
Initials: *
5. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer’s employees do not have a past record of unlawful activities. Therefore, I understand and accept that, due to the nature of the position I am applying for will constitute an extensive background investigation of any criminal or unlawful activity.
Initials: *
6. I understand and agree that, if hired, my employment and my continued employment are conditioned on my authorizing the Township to receive information from the Ohio Bureau of Motor Vehicles relating to my driving record, and any traffic violation points, pursuant to ORC 4507.40, that I have accumulated. Accumulation of more than 6 such points during any 24 month period may in the sole discretion of the Scioto Township Board of Trustees, be grounds for immediate dismissal.
Initials: *
I solemnly swear of affirm that all of the information furnished in this employment application is true, accurate, and complete to the best of my knowledge. I authorize the investigation of all statements contained in this application. I understand that any misrepresentation or falsification may lead to the withdrawal of any employment offer or dismissal of employment. I also recognize that my future employment with the employer will be jeopardized if I engage in substance abuse.
Signature: *
Date: *
Disqualification Criteria The public places a higher level of trust and standards for firefighters. The following criteria will disqualify any potential candidate from employment with the Scioto Township Fire Department. 1. Failure to provide complete and accurate information in the application 2. Any deception, falsehood or misleading statement during an interview 3. Failure to disclose criminal records 4. Any theft criminal record 5. Any fraud criminal record 6. Any sexual criminal record 7. Any child abuse criminal record 8. Any domestic violence criminal record 9. Any gambling criminal record 10. Any history involving the sale or trafficking of a controlled substance 11. Substance abuse history within 3 years 12. Any OMVI or DWI within 6 years 13. More than one OMVI or DWI 14. Any conviction of vehicular homicide 15. Any drivers’ license suspension within 3 years 16. More than one drivers’ license suspension 17. Being uninsurable with our insurance provider 18. Failure of a drug test or failing to take a drug test 19. A history of poor work performance or poor attendance/tardiness from employers 20. Poor disciplinary records from employers 21. Inability to get along with others 22. A dishonorable discharge from military service 23. Non-compliance with a court order to provide child support or alimony. 24. Violation of a restraining order 25. History of accepting favors, gifts or bribes in the course of public service 26. Admission or history of racial, ethnic, or social intolerance 27. Admission of theft or receiving stolen property 28. Verification or admission to having cheated on any examination 29. Any medical condition that would prevent one from performing the duties of a firefighter Candidate, Thank you for your interest in being a fire fighter with the Scioto Township Fire Department. Please include the following information with your application: 1. Resume 2. Copy of driver license 3. Copy of any valid Ohio fire certifications a. Minimum Ohio FireFighter II Card (240) b. CPR Card c. Minimum Ohio First Responder/Ohio EMT Certification. 4. If you have had a physical in the last year, please include this information
Resume:
Copy of driver license: *
Copy of any valid Ohio fire certifications: *
If you have had a physical in the last year, please include this information:

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