Emergency Services District #4

TRAVIS COUNTY EMERGENCY SERVICES DISTRICT #4

FIRE AND EMT ACADEMY CADET CLASS XVII APPLICATION

District Office 11800 North Lamar #4B Austin, Texas 78753 (512) 836-7566 READ ALL OF THE MINIMUM REQUIREMENTS AND AUTOMATIC DISQUALIFIRERS BEFORE COMPLETING THE APPLICATION. MINIMUM REQUIREMENTS  Must be 18 years of age as of September 30, 2016.  Must have High School or GED diploma.  Must have a valid driver’s license.  Must be a U.S. citizen.  Must be able to commit to 40 + hours a week, including occasional weekends.  Must complete a minimum of 2 – Twelve (12) hour authorized ride-outs with ESD #4 by September 30, 2016. AUTOMATIC DISQUALIFIERS Important: If you are not sure if any of the automatic disqualifiers pertain to you, you are required to submit a detailed letter explaining the circumstances in question. Application Disqualifiers The following will disqualify the applicant from further consideration during any phase of the process. 1. Failure to submit the application and all required documents by the September 30, 2016 deadline. Criminal Disqualifiers A. Any of the following will disqualify the applicant from further consideration during any phase of the process. 1. Having a conviction for, or being under indictment for, or currently charged with any felony offense. 2. Having any conviction for any Class A or Class B misdemeanor offense, or currently being under indictment for, or currently charged with any Class A or Class B misdemeanor offenses within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy. 3. Having a conviction for driving under the influence (DWI/DUI) or being under indictment for, or currently charged with driving under the influence (DWI/DUI) within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy. 4. Currently serving community supervision/probation for any offense. For the purposes of the above requirements, a person is considered convicted of an offense when an ADJUDICATION OF GUILT is entered against said person by a court of competent jurisdiction, or a PLEA OF GUILTY is entered, including situations where: 1. The sentence is subsequently probated and the person is discharged from probation. 2. Deferred adjudication is granted. B. Having excessive records of traffic convictions or negligent traffic collisions. This is defined as: 1. Involvement as a driver in three or more motor vehicle accidents within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy, where the applicant’s actions contributed to the accident in any way, whether or not citations were issued. 2. Convictions for more than two moving violations within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy. 3. A driver’s license suspension within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy for:  DWI/DUI  Failure to carry liability insurance

TC ESD #4 Fire/ EMT Academy Application-2017 1 Military Disqualifiers 1. Having been released from military service with a DISHONORABLE discharge.

Drug Use Disqualifiers (All cadets are subject to random drug testing.) 1. Illegal use of Marijuana, any controlled substance or illegal drug, within the past 5 years as of September 30, 2016 and or any time prior to the start of the Academy. 2. Having a police record of illegal drug usage or having illegally furnished any illegal or dangerous drug to another. General Disqualifiers 1. Currently, have belonged to, or been closely associated with any organization which advocates or engages in unlawful conduct directed at individuals or groups based upon the individual’s or group’s race, sex, religion, national origin, age, sexual preference, disability, or conduct otherwise commonly known as “Hate Crimes”. 2. Making any false statement of fact, being deceptive by statement or omission in this application, or by any means in any part of the hiring process will result in disqualification and may be grounds for future dismissal.

Applications must be submitted by 4:00 pm CST on September 30, 2016

Please carefully read all of the material in the enclosed Application. All documents requested must be obtained and returned with the completed application. Each line item or question must be addressed, “N/A” (not applicable) if necessary. Unanswered items or questions will be considered incomplete and the application will not be processed. Instructions for obtaining requested documentation is enclosed, as well as an overview of the application process. 1. Applications can be typed or handwritten. Submit the completed application with required documents to the District Office, 11800 N Lamar Blvd., Ste 4B., Austin, TX 78753. The application cannot be submitted online. 2. After the application is submitted to the District Office, the criminal history and driving record will be reviewed by the Travis County ESD #4 Fire Chief. 3. All applicants will be notified by October 14, 2016 whether they will advance to the candidate phase of the process.

4. Advancing candidates will return to the District Office to pick up Candidate Packets.

5. There will be a written and physical exam. There may be an oral interview process. 6. Final cadet selection will be based on the entire application process. 7. The final cadet list for Class XVII will be selected by November 4, 2016.

TC ESD #4 Fire/ EMT Academy Application-2017 2 ALL APPLICANTS MUST SUPPLY THE FOLLOWING DOCUMENTS

 Completed and signed application  Copy of Fire/EMT Certificates, if applicable  Original DPS criminal history * see below  Copy of College transcripts, if applicable  Original DPS driving record-Type 3 *see below  Copy of Valid Driver’s License  Copy of Immunization records * see below  Copy of Valid Social Security card  Copy of High School Transcripts or GED Test Scores  Copy of Military DD214, if applicable  Copy of High School Diploma or GED Certificate

*To obtain a DPS Criminal History go to: 108 Denson Dr., Austin, TX 78752 - Need valid ID for Texas Criminal History Background - Monday – Friday 8am-5pm - Will accept cash, check, or money order, NO CREDIT CARDS - NO Fingerprint card needed - Allow 1 to 2 days to pick it up, or have it mailed to you

*To obtain a Driving record online go to: www.txdps. state . tx .us - Click on services, then Driver’s license/ID, then Driver Record Request, then “order now”, follow instructions. - Type 3 Record is required

*Immunization record to include: - Tetanus (Td) current within 10 years - MMR – 2 doses - Varicella or proof of chicken pox disease - Hepatitis B – 3 doses, if applicable - TB (Tuberculosis)

TC ESD #4 Fire/EMT Academy Application-2017 3

PERSONAL INFORMATION

Date: Name:

Last First Middle Address: Apt #:

City: State: Zip:

Social Security :

Date of Birth:

Driver’s License Number : State: Class:

Home Phone Number: Cell Number:

Email Address:

EDUCATION

High School Name and location of High School Last Attended Did you Graduate?

 Yes  No If you have not graduated from High School, have you passed the GED Test? GED  Yes  No Place: Name and Location of School Courses Certification Received  Business Completed

 Technical

 Vocational

Colleges or Universities Location Hours completed Graduated Degree Received to date Yes No  

Yes No  

TC ESD #4 Fire/ EMT Academy Application-2017 4 MILITARY SERVICE

Military Service :  Yes  No Branch of Service: Date of Enlistment: Year of Discharge: Type of Discharge: Grade/Rank:

EMPLOYMENT EXPERIENCE Start with your present job. Include any job-related military service assignments and volunteer activities.

Employer:

Phone Number:

Job Title: Supervisor’s Name:

Starting Date: End Date: Reason for Leaving:

Employer:

Phone Number:

Employer:

Phone Number:

TC ESD #4 Fire/ EMT Academy Application-2017 5

PREVIOUS FIREFIGHTER/EMT TRAINING

Firefighter (if applicable) EMT Training (if applicable)  Volunteer  Basic  Intermediate  Paramedic Name of Department:

TDSHS #: Expires: Years of Service: NREMT#: Expires:

Level of Training:

Reason for leaving:

REFERENCES List three references (if applicable, use only one from Travis County ESD#4)

Name: Phone Number:

Address:

City: State: Zip:

Years known: Relationship:

Name: Phone Number:

Address:

City: State: Zip:

Name: Phone Number:

Address:

City: State: Zip:

EMERGENCY CONTACT Name: Phone #: Name: Phone #:

ACKNOWLEDGEMENT

Please read carefully, initial each paragraph and sign below.

I understand that this application and any attachment(s) are the property of Travis County ESD #4 and will become part of my personnel file. ______(Initial here) I hereby certify that the information in this application is true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any misrepresentation, falsification or omission of information from this application shall be grounds for rejection of this application or immediate discharge regardless of the time elapsed before discovery. ______(Initial here)

I hereby authorize Travis County ESD #4 and its agents to thoroughly investigate the information on my application, my references, work record and education. In addition, I hereby release Travis County Emergency Services District #4, my former employers and all other persons or entities from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. ______(Initial here) I acknowledge that I may be subjected to random drug and alcohol testing at any time. ______(Initial here) I acknowledge that Travis County ESD #4 will not provide medical healthcare coverage at any time.______(Initial here)

I agree to abide by the Travis County ESD #4 policies, rules and regulations. I understand and agree that Travis County ESD #4 is an ‘at will’ employer and my services may be terminated at any time. ______(Initial here) I understand that Travis County ESD #4 Fire/EMT Academy is a volunteer academy and I will not be considered an employee if selected during the academy. ______(Initial here)

______Applicant’s Signature Date

______Printed Name