RETURN TO: PEND OREILLE COUNTY Pend Oreille County Fire District 4 FIRE PROTECTION EMPLOYMENT 11 Dalkena Street DISTRICT 4 APPLICATION Newport WA 99156
EQUAL EMPLOYMENT OPPORTUNITY - AFFIRMATIVE ACTION EMPLOYER - DRUG-FREE WORKPLACE
APPLICATION FOR: Title of Position: Date of Application:
APPLICANT INFORMATION: Last Name: First: M.I. Social Security #
Mailing Address City State Zip Code
Daytime Phone ( ) Evening/Message Phone ( )
Do you possess a valid driver=s license? Yes No Issuing State: License No. Expiration Date:
Are you legally authorized to work in the United States? Yes No Are you 18 years of age or older: Yes No
Americans with Disabilities Act: Are you able to perform the essential duties listed on the job descriptions for this position? Yes No with accommodation without accommodation What accommodation will you need? ______
CRIMINAL CONVICTIONS: Have you been convicted of a felony within the last seven years? ______If yes, explain on an attached sheet and include: 1) date 2) charge 3) place 4) action taken
LICENSES AND CERTIFICATES (Professional or trade licenses which are required for the position) Description Issued By Expiration Date
EDUCATION:
Circle highest grade completed: 8 9 10 11 12 GED College: 1 2 3 4 Grad Work? G Yes G No
NAME AND LOCATION ACADEMIC MAJOR DATES UNITS COMPLETED DEGRE YEAR SKILL OR TRADE TO FROM SEM QTR E
OTHER QUALIFICATIONS: (Summarize special job-related skills and qualifications acquired from employment or other experience)
If you are selected to participate in an examination or interview and need any special accommodation in order to complete or participate in the process because of an impairment or disability, please notify a member of the Personnel staff. EMPLOYMENT HISTORY: Respond completely to the information requested. Attempt to cover all requirements listed in the job posting. List your most recent employment first. Please explain any gaps of a year or more in employment history. List all experience, paid and voluntary, related to the position for which you are applying. Failure to provide all information may result in rejection of your application. Resumes will not be accepted in lieu of completing this application, but may be attached to the application.
To list additional job duties, use extra employment history sheets.
Business or Agency Name: Dates Employed: Job Title: Number of Persons Supervised:
Address: From: To: Duties:
Phone: Hours per Week:
Supervisor Name: Final Salary:
May we contact this employer: Yes No Reason for leaving or considering leaving:______
Business or Agency Name: Dates Employed: Job Title: Number of Persons Supervised:
Address: From: To: Duties:
Phone: Hours per Week:
Supervisor Name: Final Salary:
May we contact this employer: Yes No Reason for leaving or considering leaving:______
Business or Agency Name: Dates Employed: Job Title: Number of Persons Supervised:
Address: From: To: Duties:
Phone: Hours per Week:
Supervisor Name: Final Salary:
May we contact this employer: Yes No Reason for leaving or considering leaving:______
AUTHORIZATION AND CERTIFICATE I authorize Pend Oreille County Fire District 4 at the time of my application for employment and during the course of my employment to verify information contained in this application as it relates to the position for which I am being considered or in which I may be employed. I certify that my statements in this application are true, complete and correct to the best of my knowledge and belief. I understand that any falsification or omission of information may bar me from the examination, remove my name from eligibility list, or if I have been hired, cause my dismissal from Pend Oreille County Fire District 4. I understand all of the statements made on this application may be investigated. I authorize employers, schools or persons named in this application to give any information regarding my qualifications and character. I hereby release said employers, schools, persons and Pend Oreille County Fire District 4 from any liability or damages for receiving or releasing information. Federal law requires anyone employed by a State Entity present proof of identity and proof of authorization to work in the United States. I understand I must be able to prove this authorization. I understand that any offer of employment is contingent upon my agreeing to submit to and obtaining satisfactory results from a pre-employment urine drug screening if required. Further, I understand that I may be required to undergo a physical examination and employment is contingent on meeting Pend Oreille County Fire District 4's physical requirements. DATED: ______SIGNATURE:______