Fire Department Employment Application

Personal Information

Date

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

General Questions

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the US?

Yes
No

Are you currently certified in CPR/AED?

Yes
No

CPR Card Expiration Date

If yes, please provide expiration date

Have you ever been convicted of a felony?

Yes
No

If yes, please explain:

Do you have any experience in Fire Service/EMS?

If yes, please list your previous three agencies

Education

any in you

High School Name

Did you graduate?

Yes
No

Additional Education — Please List:

Your Current Highest Level of EMS/Medical Licensure

Do you possess a current National Registration with the NREMT?

Fire Service Certifications

What Fire Service Certifications Do You Hold? (Check all that apply)

What NIMS/ICS Classes Have You Taken & Passed? (Check all that apply)

List any other Fire Service/EMS Training Classes you have taken and passed:

List any Organizations, Clubs, or Trade Associations you are or have been a member of:

Employment History

Please list your most recent first.

Employer

Employer Name

Job Title / Position

Address

Starting / Ending Dates

Responsibilities

Reason for Leaving

May we contact this Employer?

Yes
No

Authorization & Certification

I authorize the City of Girard to conduct a background check / driver's license check through the Kansas Department of Revenue, Divisions of Vehicles. I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Driver's License #

Authorization

I authorize the City of Girard to conduct a background check / driver's license check through the Kansas Department of Revenue, Divisions of Vehicles.

Electronic Signature

Certification

I certify all information provided is true and accurate

Date