<p> CITY OF LYNDEN FIRE DEPARTMENT</p><p>Fire Chief Gary Baar Assistant Fire Chief Robert Spinner</p><p>APPLICATION FOR VOLUNTEER FIRE FIGHTERS</p><p>Qualified applicants receive consideration for employment without discrimination because of sex, marital status, race, color, religion, national origin, age, sex, sexual orientation, veteran status or the presence of a non-job-related handicap. Conditions of employment are stated at the end of this form. Please read carefully before you sign this application. False statements on this application form shall be considered sufficient cause for termination. You may attach separate sheets if necessary to answer fully any questions on this application.</p><p>Name______Date______(Please print) Last First Middle</p><p>Address______Street City State Zip Email Address______</p><p>Home Phone______Message Phone______</p><p>Cell Phone______Pager______</p><p>Available for: Full Time_____ Part Time_____ Temporary_____ Date Available______</p><p>U.S. Citizen, or do you have a visa permitting you to work in the U.S.? Yes [] No []</p><p>Social Security Number (optional):______</p><p>Do you possess or can you obtain a valid Washington State Driver’s License? Yes [] No []</p><p>Drivers License Number:______State:______</p><p>Expiration Date:______</p><p>Are you willing to work nights and weekends in the line of duty? Yes [] No []</p><p>Who should we contact in an emergency?</p><p>Name:______Telephone:______</p><p>Your spouse’s name:______EDUCATION</p><p>Circle Last Last Date Graduated Name and City Major/Subject Year Attended Attended (Degree) High School: Month/Year 1 2 3 4</p><p>College: Month/Year 1 2 3 4</p><p>Graduate School: Month/Year 1 2 3 4 </p><p>Business/Trade School/Other: Month/Year 1 2 3 4</p><p>EXPERIENCE</p><p>Do you have any fire service or emergency medical experience? Yes [] No []</p><p>Agency:______Dates:______</p><p>City/State/Phone:______Supervisor:______</p><p>Agency:______Dates:______</p><p>City/State/Phone:______Supervisor:______</p><p>Agency:______Dates:______</p><p>City/State/Phone:______Supervisor:______</p><p>Are you certified as a Washington State Emergency Medical Technician? Yes [] No []</p><p>List any special training, experience or certifications you have in the fire or emergency medical services, or any fields you believe are related:______</p><p>______</p><p>______</p><p>______WORK HISTORY</p><p>List below your current and former employers, beginning with the most recent. Attach separate sheets if necessary.</p><p>(Include Full-Time or Part-time Jobs, Summer Jobs, Businesses of Your Own, Volunteer work)</p><p>(1) Employer: Job Title: Employment Dates:</p><p>Address: Duties: From:</p><p>City/State: To:</p><p>Supervisor: Phone:</p><p>(2)Employer: Job Title: Employment Dates:</p><p>Address: Duties: From:</p><p>City/State: To:</p><p>Supervisor: Phone:</p><p>(3)Employer: Job Title: Employment Dates:</p><p>Address: Duties: From:</p><p>City/State: To:</p><p>Supervisor: Phone: REFERENCES</p><p>Please list the name and telephone numbers of at least three persons who can attest to your character and abilities.</p><p>Name:______Telephone:______</p><p>Name:______Telephone:______</p><p>Name:______Telephone:______</p><p>CRIMINAL CONVICTIONS</p><p>Have you been convicted of a criminal offense (misdemeanor or felony or driving infraction—this does not exclude you) in the last seven (7) years? Yes [] No []</p><p>If yes, please provide details and/or comments:______</p><p>______</p><p>______</p><p>______</p><p>PLEASE NOTE: A. Applicant agrees to the following conditions of employment:</p><p>1. Meeting minimum or maximum age requirements of applicable laws and submitting proof of true age, if required.</p><p>2. Submitting proof of citizenship or U.S. work permit, at the time of or after hire, if required.</p><p>3. Completing and executing surety bond application, if required.</p><p>4. Meeting attendance and performance requirements.</p><p>5. Conforming to other agency rules, regulations and instructions.</p><p>6. Maintaining an up-to-date driver’s license if operating city vehicles.</p><p>B. Have you read the job description for Volunteer firefighter? Yes [] No []</p><p>C. Have you read the selection process handout included with this packet? Yes [] No []</p><p>D. Do you understand that if you have no prior experience, you must pass a written, oral and physical agility exam to become a member of the Lynden Fire Department? Yes [] No [] E. Do you understand that your application form will be turned over to the Lynden Police Department to conduct a criminal history and driving record background check which must be successfully passed to become a member of the Lynden Fire Department? Yes [] No [] F. Do you understand that upon successful completion of the items listed in D, E, & F above, you must still pass a physician’s medical exam, paid for by the Department, to become a member of the Lynden Fire Department? Yes [] No []</p><p>G. Do you understand that once you have been appointed to the Department you must serve a one (1) year probationary period, during which you may be subject to termination at any time without cause? Yes [] No []</p><p>H. Do you understand that if you become a volunteer fire fighter, the Lynden Fire Department makes no promises or guarantees of future employment with the fire department? Yes [] No []</p><p>I. Do you understand that you must obtain and maintain your Washington State EMT certification and successfully complete the Whatcom County Fire Academy within 2 years to become and remain on the Lynden Fire Department? Yes [] No []</p><p>PLEASE READ THE FOLLOWING AND SIGN BELOW:</p><p>I certify, under the penalty of perjury, that all statements above are true. I understand false statements shall be sufficient cause for termination.</p><p>______Signature Date</p><p>I, ______, hereby give permission for background and previous employment investigation. I waive any and all claims against any company, corporation or individual pertaining to information gained as a result of this investigation.</p><p>______Signature Date</p><p>Witness:</p><p>______Signature Date</p>