Job Application: Probationary Firefighter

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Title: Probationary Firefighter

Fields marked with an asterisk (*) must be filled out before submitting.

Do not leave any answers blank. For any questions that do not apply, please type NA for Not Applicable. You may upload a resume with the application if you wish.

Acceptance as a member of the fire department is subject to the completion of the following items:
1.) Meeting the qualifications of the position.
2.) Successful completion of a criminal background check.
3.) Successful completion of a physical examination and drug screen.
4.) Successful completion of an oral interview.
5.) Successful completion of a one-year (six-month minimum) probationary period from date of hire.

Personal Information

Full Legal Name (including middle name) *
Date of Birth *
E-Mail Address *
Address (include apartment/unit number and city/state/ZIP) *
Phone Number *
Are you entitled to work in the United States? * Yes
No
Social Security Number *
Drivers License Number, State, and Class *
 
Have you been convicted of a felony, been incarcerated in connection with a felony, had any traffic violations, or been involved in any traffic accidents in the past ten years? * Yes
No
If yes, please explain
 
Military Service? Yes
No
If yes, list branch and dates of service (attach Member 4 DD-214 if discharged)
 
Have you ever been employed by the Peoria Heights Fire Department or the Village of Peoria Heights in the past? * Yes
No
If yes, when were you employed and what was your reason for leaving?
 
Do you have any relatives currently serving with the Peoria Heights Fire Department? * Yes
No
If yes, who?
 

Education Information

High School Name (or GED Info) *
High School City/State *
Attended From *
Attended To *
Did you graduate? * Yes
No
 
College or Trade School Name
College or Trade School City/State
Attended From
Attended To
Did you graduate? Yes
No
Degree Information
 

Employment Information

Current/Most Recent Employer Name
Address (incl. City/State/ZIP)
Phone Number
Immediate Supervisor
Job Title
Work Hours
Date Hired
Date Departed (if currently employed, choose todays date)
Reason for leaving (if applicable)
May we contact this job for a reference? Yes
No
 
Employer Name
Address (incl. City/State/ZIP)
Phone Number
Immediate Supervisor
Job Title
Work Hours
Date Hired
Date Departed (if currently employed, choose todays date)
Reason for leaving (if applicable)
May we contact this job for a reference? Yes
No
 
Employer Name
Address (incl. City/State/ZIP)
Phone Number
Immediate Supervisor
Job Title
Work Hours
Date Hired
Date Departed (if currently employed, choose todays date)
Reason for leaving (if applicable)
May we contact this job for a reference? Yes
No
 

References

Reference 1 Full Name *
Reference 1 Relationship *
Reference 1 Address (incl. City/State/ZIP) *
Reference 1 Phone Number *
 
Reference 2 Full Name *
Reference 2 Relationship *
Reference 2 Address (incl. City/State/ZIP) *
Reference 2 Phone Number *
 
Reference 3 Full Name *
Reference 3 Relationship *
Reference 3 Address (incl. city/state/ZIP) *
Reference 3 Phone Number *
 

Emergency Contacts

Contact 1 Full Name *
Contact 1 Relationship *
Contact 1 Address (incl. city/state/ZIP) *
Contact 1 Phone *
 
Contact 2 Full Name *
Contact 2 Relationship *
Contact 2 Address (incl. city/state/ZIP) *
Contact 2 Phone *
 

Certifications and Fire/EMS Experience

List any applicable special skills, training, certifications, or proficiencies related to this position. Include previous Fire/EMS experience
 

Disclaimer and Signature

EEO Statement
The Peoria Heights Fire Department is an equal opportunity employer. No application can be denied solely on age, color, disability, national origin, political affiliation, race, religion, gender, sexual orientation, or other non-merit factors.
 
I certify, under penalty of perjury, that the information presented on this application is true and complete to the best of my knowledge and ability. * Yes
No
 
I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this application or subsequent examinations shall be sufficient cause to terminate my membership at any time or to deny acceptance of an applicant. * Yes
No
 
I understand that any offer of membership and any future statements by the membership does not constitute a binding contract, and that such membership is terminable at any time by either party. * Yes
No
 
I provide my authorization to conduct a background investigation prior to my membership which may include contacting previous employers, references, schools, law enforcement agencies, and other references as the department sees fit. * Yes
No
 
I understand that, should I be accepted as a member of the Peoria Heights Fire Department and later have my membership terminated (either by myself or by the department), I am required to turn in any and all equipment/clothing issued to me by the department within 14 days. I also understand that I could face potential civil or criminal action should I not return the equipment/clothing within the allotted time. * Yes
No
 
By signing, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I understand that my signature denotes acceptance and agreement of all items/terms/information listed in this application and that this is considered legally binding.

The text box below constitutes your signature as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and the Peoria Heights Fire Department. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application shall be legally binding and such transaction shall be considered authorized by you.
 
Electronic Signature (Full Name) *
Resume
DD-214
Certification 1
Certification 2
Certification 3