Employment Application - Johnson County Fire Protection District

1Applicant Information

2Education

3Employment History

4Application Agreement

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Todays Date

MM slash DD slash YYYY

Application Type*

Volunteer

Full-Time

APPLICANT INFORMATION

Name*

First Middle Last

Permanent Address*

Street Address City State ZIP Code

Daytime Phone*

Evening Phone

Cellular Phone

Social Security No.*

Drivers License No./State*

Email Address*

List Any Other Names Used

Are You A Us Citizen?*

Yes

If Not, Do You Have A Permit To Work In The US?*

Yes

Have You Ever Worked For This Company?*

Yes

If So, When?*

Date Of Birth*

Month

Day

Year

Are You Over Age 18?*

Yes

EDUCATION

List any education you've recieved.

Education Type

Location

Years Attended

Did You Graduate?

Degree Obtained

SKILLS

Describe any training/experience/special skills which would be an asset in performing the duties of the position.*

LICENSE/CERTIFICATE

List any licenses/certifications relevant to the duties of the position.

License/Certificate

Date Issued

Issuing Authority

REFERENCES

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Number Of Refrences Needed

List three references that are not related to you and have knowledge of your work history, character or ability to perform the duties of the position.*

Name

Address

Business

Phone Number

EMPLOYMENT HISTORY

List Your Previous Employers

Begin with most recent employer first.

Company	Job Title	Start Date	End Date	Actions

There are no Entries.

Maximum number of entries reached.

Have you ever been convicted of an offense other than traffic related violations?*

(as used in this application, “convicted” includes pleas of guilty, pleas of nolo contendere or findings of guilt whether or not imposition or execution of sentence is suspended)

Yes

If Yes, Explain*

Have you ever been convicted of any felony offense?*

Yes

If Yes, Explain*

Have you ever been convicted of more than one misdemeanor offense?*

Yes

If Yes, Explain*

Have you ever been convicted of any drug related offense?*

Yes

If Yes, Explain*

Have you ever been convicted of perjury?*

Yes

If Yes, Explain*

Are there any current pending criminal charges against you?*

Yes

If Yes, Explain*

DISCLAIMER AND SIGNATURE

Agreement*

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, any false or misleading information given in this application or accompanying documentation may be grounds for dismissal.*

Agreement*

I authorize investigation of all information provided, my character, reputation and abilities. I also authorize the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have and release the District and those supplying such information from all liability for any damage that may result from utilization of such information.*

Agreement*

I authorize the Johnson County Fire Protection District to conduct inquiries into my driving record and to perform a criminal records background check.*

Agreement*

I understand this application is not, nor is it intended to be, a contract for employment.*

Signature*

The Johnson County Fire Protection District does not discriminate against any employee or applicant for employment regardless of economic or social status and will not discriminate on the basis of race, color, ethnic origin, national origin, creed, religion, political belief, sex, sexual orientation, marital status, age, veteran status, genetic information or physical or mental disability.