Bullard Volunteer Fire Department

Transcription

1 --- m - u Bullard Volunteer Fire Department P.o. Box 140 Bullard, TX Application for EMPLOYMENT Applicants are considered for employment without regard to race, creed, religion, sex, national origin, marital or veteran status, the presence of non-job related medical conditions, or any other legally protected status. Applicants may not volunteer and be employed within the same Fire Department. DATE: Personal Information (please type or print in blue ink) BIRTIIDA1E: HOW LONG? TELE NUMBERS: (HOME) Social Security No.. Spouse/Emergency Contact: Beneficiary: (Ist) (MOBILE) Drivers License No. Phone No. (2nd) roblation for any felony or serious mis- Have demeanor you ever otherbeen thanconvicted, a minor traffic awaiting violation? trial for, served 0 any YESsentenceNOor H yes; please explain briefly the circumstances: A conviction does not automaticallv exclude vou from emolovment consideration! MOVING VIOLATIONS (in the last 5 years) ACCIDENTS (IN THE LAST 5 YEARS) Are you a member of the State Firemen Fire Marshal's Association? If so, what is your membership no.?

2 Bullard Volunteer Fire Department P.o. Box 140 Bullard, TX Texas is an "AT WILL" state, this means that either the employee or employer may terminate employment at any point in time, without notice or recourse. No notice of intent or reasons of separation are required of "EITHER PARTY". No guarantee of employment is either expressed or implied! I have read and understand this statement. Applicant signature

3 EDUCATION SCHOOLS NAME OF SCHOOL OR COLLEGE MAJOR STUDIES LAST GRADE COMPLETED GRADUATION DATE IDGH SCHOOL COLLEGE TRADE OR BUSINESS SCHOOL MEDICAL mstory Do you have any physical or mental condition which my limit your ability to perform the job applied for; or which might pose a potential risk to other employees? YES_NO If yes: Please describe: Are you willing to submit to a physical examination if required? YES- NO- Do you agree to report any injuries, no matter how seemingly minor, to your immediate supervisor? yes_no- Have you ever been made ill by your work, suffered an occupational disease, or been seriously injured on the job? YES- NO If yes, please explain.

4 REFERENCES Please provide the names and addresses of (3) three people (NO RELATIVES) you have worked with and to whom we may refer for a reference if necessary. Employment references: Please list any of your previous employers for the past 5 years and a supervisor and contact number, so that we may contact them if necessary for a reference.

5 BACKGROUND CHECK AUTHORIZAnON AND RELEASE I have carefully read and understand this Disclosure, Authorization and Release form. By my signature below, I consent to the release of consumer reports and/or investigative reports to Bullard Volunteer Fire Department Inc. in conjunction with my job application and/or volunteer services. I also authorize disclosure to the Bullard Volunteer Fire Department Inc. and/or to the background check vendor of information concerning my employment history, earning history, education, credit history, credit capacity and credit standing, motor vehicle history and standing, criminal history and all other information the Bullard Volunteer Fire Department Inc. deems pertinent by any individual, corporation or other private or public entity, including without limitation the following: employers; learning institutions, including law enforcement agencies; federal, state and local courts; the military; credit bureaus; motor vehicle records agencies; and other applicable sources. I hereby release and hold the vendor and the Bullard Volunteer Fire Department Inc. its officers, directors, other volunteers and employees harmless from any and all liability with respect to the consumer reports, investigative reports, investigations, verifications and/or the use of any information relevant to my employment. I understand that my consent will apply throughout my employment/volunteer to the extent permitted by law. Name Social Security#.Date of Birth Present Address Driver License # State of Issue Telephone # Signature Date