Swiftwater/Wildland Application Checklist

Transcription

1 Mountain View Fire and Rescue KING COUNTY FIRE PROTECTION DISTRICT AVE SE Auburn, WA / (253) ; FAX (253) Swiftwater/Wildland Application Checklist Application complete with signature and date. W-4 Complete with signature and date. W-9 Complete with signature and date. Copy of Driver s License attached. (If out-of-state license you must be able to obtain a Washington State Driver s License within 30 days.) Insurance Beneficiary Designation Form complete with signature and date. Group Life Beneficiary Form complete with signature and date. Washington State Patrol Background reference check waiver form. Page 1 of 12

2 Mountain View Fire & Rescue King County Fire District # th Ave SE, Auburn, WA (253) Swiftwater/Wildland Application PERSONAL An incomplete application may delay or disqualify you. Do not use pencil to complete application. Name: Last First MI Street Address Home Phone City State Zip Code Cell Phone Social Security Number Address In Case of Emergency Contact: Name: Last First Relationship Street Address Home Phone City State Zip Code Cell Phone Are you prevented from lawfully becoming employed in this country because of visa or immigration status? yes no Work Permit: yes no Can you provide proof of a legal right to work in the United States after hire?: yes no Valid Washington State Driver s License Number: Will you be 18 years or older by date of examination? yes no I will require special accommodation for the testing process: yes no EDUCATION/ TRAINING Type of Schooling School & Location Date(s) of Enrollment Major Course Degree/ Date High School or GED Business or Tech Graduate Studies Page 2 of 12

3 Other Courses and Training Military Training / Certificates: Special Skills / Professional Licenses: List office equipment you can operate: List heavy equipment or machinery you can operate: Have you graduated from the Washington State Fire Service Training Recruit Academy? Yes No If yes, give date graduated and sponsoring department name Do you have a current Washington State Emergency Medical Technician Certificate? Yes No If yes, expiration date: Do you have a current Washington State First Responder Certificate? Yes No If yes, give date graduated and sponsoring department name Do you have any wild land fire fighting training or experience? Yes No If yes, give date graduated and sponsoring department name List any firefighting experience you have. WORK HISTORY Please read carefully: Resumes will not be accepted as a substitute for completing this section. Beginning with your present or most recent employment, list your work experience for at least the last ten years, including periods of self-employment and U.S. Military service. Attach separate sheets if necessary From (month & year) Company Name Your Position/ Title To (month & year) City Type of Company Salary Full Time Part Time Supervisor s Name/Title May we contact? Yes No Phone Number Duties: Reason for leaving: Page 3 of 12

4 From (month & year) Company Name Your Position/ Title To (month & year) City Type of Company Salary Full Time Part Time Supervisor s Name/Title May we contact? Yes No Phone Number Duties: Reason for leaving: From (month & year) Company Name Your Position/ Title To (month & year) City Type of Company Salary Full Time Part Time Supervisor s Name/Title May we contact? Yes No Phone Number Duties: Reason for leaving: From (month & year) Company Name Your Position/ Title To (month & year) City Type of Company Salary Full Time Part Time Supervisor s Name/Title May we contact? Yes No Phone Number Duties: Reason for leaving: Have you ever been or are you now an active member of King County Fire District 44? Yes No Page 4 of 12

5 PROFESSIONAL REFERENCES List professional references that have known you for 3 years or more: Name Address Daytime Phone Number Name Address Daytime Phone Number Name Address Daytime Phone Number Name Address Daytime Phone Number THE FOLLOWING MUST BE COMPLETED A criminal conviction will not necessarily bar you from employment. Have you been convicted of a job related crime or been incarcerated within the last 10 years? (Do not include non-criminal traffic citations) Yes NO If the answer is yes please give the nature of the crime, dates of convictions and the court in which you were convicted: AGREEMENT, CERTIFICATION and AUTHORIZATION This statement must not be altered. I hereby certify, under penalty of perjury in the State of Washington, that this application contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge and belief. I understand that falsification of this application will be grounds for elimination from further consideration of, and if employed, for dismissal at any time. I authorize my previous employers and all schools or educational and technical institutions which I have attended to furnish my record, reason for leaving and all information they may have concerning me to Mountain View Fire & Rescue (King County Fire District #44). I hereby release any such current or former employers or institutions, their agents or employees and the above listed jurisdictions from all liability for any damage whatsoever arising therefrom. I authorize investigation of all statements in this application. NOTICE: If selected you will be required to verify you are legally eligible to work in the United States prior to appointment (P.L : U.S. Immigration Reform and Control Act of 1986) Signature of Applicant Date Mailing Address (If different from your street address) Name MI Last Page 5 of 12

6 Address City State Zip Code DRIVING RECORD To be completed by applicant for the positions when operation of motor vehicles is a regular part of the job duties. Name Date of Birth Social Security Number Driver s License Number Expiration Date State of Issue List any notices of infractions or traffic citations you have received in the past 5 years: State Month / Year Type of Infraction Infractions or citations will not necessarily remove you from consideration, but Mountain View Fire & Rescue will consider your driving record and insurability when making employment decisions. Do you have a current CDL driver s endorsement? ) Yes No Waiver and Release of Driving Record I, the undersigned applicant for employment with Mountain View Fire & Rescue, hereby authorize the release of both my individual and my employee driving record, as defined by RCW and by the Department of Licensing, and my criminal record to Mountain View Fire & Rescue. I have been informed that portions of this record are my confidential property and may not be obtained without my express consent and request. If Mountain View Fire & Rescue selects me as a career or volunteer member, this release shall continue to be valid throughout the tenure of my participation with this jurisdiction. A photocopy may be accepted in lieu of the original. Print Name Signature Date MEDICAL INFORMATION Medical Questionnaire for Respirator Users Age Height Weight Past Respirator History Have you ever worn a respirator before? Yes No If yes, describe any difficulties noted with use Medical History Have you now or have you ever had any of the following? Yes Lung disease (asthma/copd) Persistent cough No Page 6 of 12

7 Heart troubles Shortness of breath History of fainting or seizures High blood pressure Diabetes Fear of tight or enclosed spaces Sensation of smothering Heat exhaustion or heat stroke Ruptured ear drum Defective vision (corrective lenses) Defective hearing Are you taking medications? Any medical problems that might affect your ability to wear a respirator? If yes to any of the above, please explain The answers to the above questions are complete, accurate, and true to the best of my knowledge. I understand that the examination includes competitive physical tests. I agree to take full responsibility for any injury or results of overexertion and hereby release King County Fire Protection District 44, Auburn, Washington and any and all parties delegated as their representatives for this testing procedure from any and all liability for ill effects resulting from these tests. I also hereby affirm that I am in good physical condition and consider myself physically capable of exerting all the necessary effort to do myself justice in these examinations. Signature Print Name Date Page 7 of 12

8 Form W-4 (2010) Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances Purpose. Complete Form W-4 so that your you claimed and may not be a flat amount or employer can withhold the correct federal income percentage of wages. tax from your pay. Consider completing a new Head of household. Generally, you may claim Form W-4 each year and when your personal or head of household filing status on your tax financial situation changes. return only if you are unmarried and pay more Exemption from withholding. If you are than 50% of the costs of keeping up a home exempt, complete only lines 1, 2, 3, 4, and 7 for yo~rself and your dependent(s) or other and sign the form to validate it. Your exemption quallfymg Individuals. See Pu~. 501,.. for 2010 expires February 16, See Exemptions, Standard Deduction, and FIling Pub. 505, Tax Withholding and Estimated Tax. Information, for Information. Note. You cannot claim exemption from Tax credits. You can take projected tax withholding if (a) your income exceeds $950 credits into account in figuring your allowable and includes more than $300 of unearned number of withholding allowances. Credits for income (for example, interest and dividends) child or dependent care expenses and the and (b) another person can claim you as a child tax credit may be claimed using the dependent on his or her tax return. Personal Allowances Worksheet below. See Basic instructions. If you are not exempt, Pub. 919: How Do I Adjust My Tax. complete the Personal Allowances Worksheet Withholding, fo~ In~ormatlon on converting below. The worksheets on page 2 further adjust your other credits mto withholding allowances. your withholding allowances based on itemized Nonwage income. If you have a large amount deductions, certain credits, adjustments to of nonwage income, such as interest or income, or two-earners/multiple jobs situations. dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for. Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 919 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 919 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the amount you are having withheld compares to your projected total tax for 201 O. See Pub. 919, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Personal Allowances Worksheet (Keep for your records.) A Enter "1" for yourself if no one else can claim you as a dependent. BEnter "1" if: You are married, have only one job, and your spouse does not work; or!.you Your are wages single fromand a second have only job or oneyour job; spouse's or wages (or the total of both) are $1,500 or less. I CEnter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-" may help you avoid having too little tax withheld.). D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return E Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) FEnter "1" if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. Ifyour total income be lessthan $61,000 ($90,000if rrarried), enter "2" for each eligible child; t!'en less "1" if you have three or more eligible children. if your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter "1" for each eligible child plus "1" additional if you have six or more eligible children. G H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ~ H A B C D E F e Service complete all and Adjustments Worksheet on page 2. worksheets Ifyou have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed that apply. $18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. For accuracy, 1. If if you neither planoftothe itemize above or situations claim adjustments applies, stoptohere income and and enterwant the number to reducefrom yourlinewithholding, H on 5 see of Form the Deductions W-4 below. Cut here and give Form W-4 to your employer. Keep the top part for your records Type ~ Whether you are entitled to claim a certain number of allowances or exemption OMSNo from withholding is Your orsocial print your security first name number subject and middle to review initial. by the IRS. Your employer may required to send a copy of this form to the IRS. Form W-4 Employee's Withholding 3 0 Single Allowance 0 Married 0 Total Additional I claim number amount, of allowances if any, you you want are claiming withheld (from each line H paycheck above 4 If your last name differs from Certificate Married, that shown but withhold on your at social higher security Single rate. card, Note.Ifmarried,butlegallyseparated, check here. You must call for orspouseisanonresident IaLast replacement alien,checkthe"single"box. name card. I 2~ 0 or from the applicable worksheet on page 2) $ exemption from withholding for 2010, and i.certify that I meet both of the following ~ conditions 171 for exemption. I you meet both conditions, write "Exempt" here. ~@10 Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete. Employee's signature (Form is not valid unless you sign it.) ~ 8 Employer's name and address (Employer:Complete lines 8 and 10 only if sending to the IRS.) Date ~ 9 Officecode(optiooaJJ I 10 Employeridentificationnumber(EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2010)

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10 Mountain View Fire & Rescue BVFF Disability Beneficiary Designation Form Name Date of Birth Last / First / Middle Address Social Security: Phone Number ( ) - Cell Phone ( ) - **PRIMARY BENEFICIARY NAME** REQUIRED DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER SECONDARY BENEFICIARY NAME DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER SIGNATURE & DATE Please return to: King County Fire District th Ave SE Auburn, WA Fax Page 8 of 21 V:\KCFD Website\academy\Vol Application doc

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12 Mountain View Fire and Rescue REFERENCE CHECK WAIVER WAIVER AND AUTHORIZATION TO RELEASE INFORMATION To Whom it May Concern; I hereby authorize you to furnish King County Fire Protection District No th Ave SE Auburn, WA with all information that you may have concerning me, my work records, and/or my financial status. Information of confidential or privileged nature may be included. Your reply will be used to assist the Fire Department in determining my fitness and qualifications for the current position I hold or am seeking with the Department. I hereby release you, your organization, and all others from any and all liability or damage which may result from furnishing the information requested. Signature Full Name (please print) Birth Date Date Records requests to be made: Washington State Patrol, RCW10.97 State of Washington Department of Motor Vehicles, RCW Other records requests as deemed necessary to conduct KCFD44 business. Page 12 of 12