Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Position Applied For(Required)

Date of Application

Type(Required)

Have you ever been employed or educated under another name? If yes, please state name(s):(Required)

Yes

Additional Name(s)(Required)

Have you ever filed an application for employment or been employed by this agency before? If yes, give date(s):(Required)

Yes

Dates of previous employment / application(Required)

Are you legally eligible for employment in the United States?(Required)

Yes

Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?(Required)

(conviction will not necessarily disqualify an applicant from employment.) If yes, please provide date(s) and details:

Yes

Conviction Details(Required)

What is your desired salary range or hourly rate of pay?(Required)

$_____ Per ______

Will you work overtime if required?(Required)

If No, please explain

Yes

Overtime Explanation(Required)

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?(Required)

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by lay.

Yes

Work Experience - Most Recent

Employer(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employed From(Required)

Employed To(Required)

Name Of Supervisor(Required)

First Last

Compensation Start(Required)

Compensation End(Required)

Job Title(Required)

Job Description(Required)

Why Did You Leave?(Required)

Work Experience - #2

Employer(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employed From(Required)

Employed To(Required)

Name Of Supervisor(Required)

First Last

Compensation Start(Required)

Compensation End(Required)

Job Title(Required)

Job Description(Required)

Why Did You Leave?(Required)

Work Experience - #3

Employer(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employed To(Required)

Employed From(Required)

Name Of Supervisor(Required)

First Last

Compensation Start(Required)

Compensation End(Required)

Job Title(Required)

Job Description(Required)

Why Did You Leave?(Required)

We may contact the employers listed above unless you indicate those you do not want us to contact.(Required)

DO NOT CONTACT & REASON:

Education - Graduate

Name & Location of School(Required)

Course of Study(Required)

Years of Study(Required)

Degree(Required)

Education - College

Name & Location of School(Required)

Course of Study(Required)

Degree(Required)

Years of Study(Required)

Education - High School

Name & Location of School(Required)

Course of Study(Required)

Years of Study(Required)

Degree(Required)

Education - Other

Name & Location of School(Required)

Course of Study(Required)

Years of Study(Required)

Degree(Required)

List work related special accomplishments, publications, awards, etc.(Required)

Training

If you have completed any other courses or training related to the job posting, please indicate below.

#1 - Month/Year Training Completed

#1 - Total Classroom Hours

#1 - Course Title

#1 - Name/Location of School or Facility (City/State)

#1 - Certificate/Diploma (if any)

#2 - Month/Year Training Completed

#2 - Total Classroom Hours

#2 - Course Title

#2 - Name/Location of School or Facility (City/State)

#2 - Certificate/Diploma (if any)

#3 - Month/Year Training Completed

#3 - Total Classroom Hours

#3 - Course Title

#3 - Name/Location of School or Facility (City/State)

#3 - Certificate/Diploma (if any)

#4 - Month/Year Training Completed

#4 - Total Classroom Hours

#4 - Course Title

#4 - Name/Location of School or Facility (City/State)

#4 - Certificate/Diploma (if any)

#5 - Month/Year Training Completed

#5 - Total Classroom Hours

#5 - Course Title

#5 - Name/Location of School or Facility (City/State)

#5 - Certificate/Diploma (if any)

Fire & Emergency Medical Experience

Have you ever been a member of a volunteer or on-call fire department, rescue squad, emergency medical service provider, or similar organization?(Required)

Yes

Name of Organization(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dates of Service(Required)

Supervisor(Required)

Reason for Leaving(Required)

List all related training that you have completed(Required)

Military Service Record

Have you ever served in the U.S. Military Service?(Required)

Yes

List branch,dates, and skills acquired ( including special training):(Required)

References

#1 - Full Name of Reference(Required)

#1 - Present Business or Home Address(Required)

#1 - Telephone Number(Required)

#2- Full Name of Reference(Required)

#2 - Present Business or Home Address(Required)

#2 - Telephone Number(Required)

#3 - Full Name of Reference(Required)

#3 - Present Business or Home Address(Required)

#3 - Telephone Number(Required)

Applicant Statement

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of 30 days or the close of position posting. At the conclusion of that time, if I have not heard from the employer and still with to be considered for employment, it may be necessary for me to reapply and fill out a new application. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Upper Pine River Fire Protection District is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time without causes. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of Upper Pine River Protection District specifically acknowledges such change in writing. I also understand that upon a job offer, I will be asked to submit to a background check, and if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICATION STATEMENT I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature(Required)

Name Typed(Required)

Date Signed

Job Application

Work Experience - Most Recent

Work Experience - #2

Work Experience - #3

Education - Graduate

Education - College

Education - High School

Education - Other

Training

Fire & Emergency Medical Experience

Military Service Record

References

Applicant Statement

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