Which Position are applying for?

EMT

Firefighter

MPO

Personal Information

Date

Last Name *

Middle Name *

First Name *

Address *

City *

State *

Zip *

Home Phone *

Cell Phone *

Date of Birth *

Place of Birth

Social Security # *

Driver's License # and State *

Email Address *

Have you ever filled out an application with us before? * YesNo

If yes, give approximate date

Have you ever been employed with us before? * YesNo

If yes, give approximate date

Have you ever been bonded? * YesNo

If yes, indicate reason

May we contact your present employer? * YesNo

Are you 18 years of age or older? * YesNo

Can you provide proof of eligibility for employment in the United States? * YesNo

Education

High School Attended

Location

Did you graduate?

Year

College Attended

Location

Did you graduate?

Major

Year(s) attended

Degree/Diploma/Total Credits

College Attended

Location

Did you graduate?

Major

Year(s) attended

Degree/Diploma/Total Credits

College Attended

Location

Did you graduate?

Major

Year(s) attended

Degree/Diploma/Total Credits

Special Skills

List proficiencies with any heacy equipment, industrial equipment, or specialized training:

List any computer skills you possess, i.e. hardware, software, programming skills etc..

List any other special skills or certifications.

Employment

Please give accurate, complete, full-‐time and part-‐time employment history including military service. Start with your most recent employer FIRST. If self-employed, give firm name and business references. If necessary, attach additional sheets using the same format.

Company Name

Address

City

State

Zip

Phone

Name of Supervisor

Employed (Month and Year)From - To

Job Title and Description

Reason for Leaving

Add other Employeer

Criminal History

Have you ever been convicted of any law violation in the last ten years, including traffic violations? YesNo

If yes, please list:

	Date	Location	Violation	Dispostion

References

Please list three persons who have knowledge of your experience and qulifications for this position, preferably current or previous supervisors, co-workers, instructors, etc.. Do not inclued relatives. If you are know to your references by another name, please note.

Name

Relationship

Address

Telephone

City

State

Zip

Years Acquainted

Add another Reference

Other Information

Is there any reason that your present health condition would restrict you from your activities as a firefighter, first responder, driver/operator or emergency medical service provider? YesNo

If yes, explain:

Do you suffer from any fear/phobias that would restrict your activities as a firefighter, first responder, driver/operator or emergency medical service provider? YesNo

If yes, please explain:

Emergency Contact

Name

Relationship

Address

City

State

Zip

Add additonal Emergency Contact

I agree to permit the Butler Volunteer Fire Dpartment, Inc. to conduct an investigation into my background through the police department, state law enforcement organizatinos, FBI, or any other recongnized law enforcement organization. The Butler Volunteer Fire Departmnet, Inc. will hold this information in confidence.

I agree that all informaion provide is accurate and to all questions asked of me. * YesNo