South Whidbey Fire / EMS Proudly Serving Since 1950 Thank you for your interest in becoming a Part-Time Firefighter/EMT for South Whidbey Fire / EMS. This is an exciting and rewarding opportunity and we look forward to meeting you. Please follow the steps below to successfully complete the application process. MINIMUM ENTRY REQUIREMENTS Be at least 18 years old. Possess a high school diploma, GED or equivalency qualification. See attached job descriptions and requirements. Have a valid State of Washington Driver s License. Be of good moral character. Have not been convicted of a felony, a crime against a person, or crime against a child. Pass a drug screen provided by the department. Complete a physical, entrance exam and work capacity test, provided by the department. APPLICATION PROCESS Applications must be submitted by the closing date posted in the announcement. Applications may be received in person or by mail / courier. Carefully read and answer all questions in this packet truthfully. Enclose a copy of all your Fire/EMS certifications. Page 5 of this application needs to be notarized. W e have a notary on staff at the Freeland Station. Monday-Friday 9:00-4:00, you are welcome to us e our notary. If you have any questions regarding the application or the process of becoming a part time firefighter/emt please contact us: 360-321-1533 or ops@swfe.org Applications can be mailed or dropped off at the Freeland Fire Station 5535 Cameron Rd. Freeland, WA 98249 (Monday-Friday 9:00-4:00) www.swfe.org
South Whidbey Fire / EMS Proudly Serving Since 1950 5535 Cameron Road Freeland, WA 98249 Telephone: (360) 321-1533 ffffff Fax: (360) 321-9385 Part-Time Firefighter/EMT PERSONAL Date: Name: (Include all legal names used) Physical Address: Mailing Address: Home Phone: Cell Phone: Email Address: EDUCATION Name and location of high school attended: Did you graduate: Yes No If you are not a high school graduate, do you have a GED: Yes No If yes, please provide the date: Continued education, college, trade school, etc.
REFERENCES (Please do not list former employers or relatives) Name: Phone Number: Address: How do you know this person: Name: Phone Number: Address: How do you know this person: Name: Phone Number: Address: How do you know this person: EMPLOYMENT HISTORY Current Employer: Phone Number: Dates of Employment: Work Schedule: Specific Duties: Previous Employer: Phone Number: Date of Employment: Specific Duties: Reason for Leaving:
FIREFIGHTER EXPERIENCE Department/Agency: Phone Number: Dates of Service: Supervisor: Position(s) Held: Reason for Leaving: Department/Agency: Phone Number: Dates of Service: Supervisor: Position(s) Held: Reason for Leaving: EMS EXPERIENCE Department/Agency: Phone Number: Dates of Service: Supervisor: First Responder EMT Paramedic Other Do you have a current Health Care Provider Card, Yes No Are you current with your continuing medical education (CME) requirements for the last certification period? Yes No Reason for Leaving: Department/Agency: Phone Number: Dates of Service: Supervisor: First Responder EMT Paramedic Other Do you have a current Health Care Provider Card, Yes No Are you current with your continuing medical education (CME) requirements for the last certification period? Yes No Reason for Leaving:
PERSONAL STATEMENTS Why are you interested in employment with SWFE? Do you have any physical limitations or health concerns that may preclude you from performing the duties of a part time firefighter or EMT? Yes No If yes, please explain: How did you hear about South Whidbey Fire / EMS and our Part-Time program? PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION I certify the information I have provided is true, correct and complete to the best of my knowledge. I certify _ that I have not and will not withhold any information that would unfavorably affect my application for a volunteer position. I understand the information contained in this application will be verified by South Whidbey Fire / EMS. I understand any misrepresentations or omissions may subject me to disqualification as an applicant _ for a firefighter position, or terminate my position as an at-will employee. _ I further understand this is an application only and does not commit South Whidbey fire / EMS in any way to accept me as a employee. Signature of Applicant Date
Confidential Disclosure Report RCW 43.43.834(2) requires South Whidbey Fire / EMS, at the time it accepts an application for the position of volunteer or paid firefighter, to obtain the following information from the applicant if the applicant, when hired, may have unsupervised access to children under sixteen (16) years of age or developmentally disable persons or vulnerable adults during the course of employment or where a volunteer may have access to groups of five (5) or fewer children under the age, or developmentally disable person or vulnerable adults. To comply with the statutory requirements, please provide the following information under oath: Have you been convicted of any crime against children or other persons? Yes No Have you been convicted of crimes relating to financial exploitation of a vulnerable adult? Yes No Have you been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor? Yes No Have you been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor? Yes No Have you been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disable person or to have abused or financially exploited any vulnerable adult? Yes No SIGN AND DATE IN FRONT OF A NOTARY Date: STATE OF WASHINGTON County of Applicant: ACKNOWLEDGEMENT OF INDIVIDUAL I certify that that I have satisfactory evidence that is the person who appeared before me, and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and purpose mention in the instrument. Date: See reverse side for an explanation Notary Public in and for the State of Washington, residing in My appointment expires
A crime against children or other persons is defined by the stature as: a conviction of any of the following offenses: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; first or second degree rape of a child; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; or any of these crimes as they may be renamed in the future. A crime relating to financial exploitation is defined by statue as: conviction for first, second, or third degree extortion; first, second or third degree theft; first or second degree robbery; forgery; or any of these crimes s they may be renamed in the future. If you are offered a position as a paid employee or volunteer with the district, the district may under RCW 43.43.832 and.834 submit an inquiry to the Washington State Patrol to conduct a records check to verify the answers provided on the reverse side. You will be notified within ten (10) days after a response is received from the State Patrol of the nature of the response and be provided a copy of the response at your request. The District will use this information and record only to make the initial employment decision and for no other purposes.
BACKGROUND SCREENING APPLICANT INFORMATION FORM PLEASE PRINT YOUR NAME AS SHOWN ON DRIVER'S LICENSE Black Or Blue Ink Only FIRST MIDDLE LAST MAIDEN / AKA SOCIAL SECURITY NUMBER STATE ISSUED DATE OF BIRTH (MONTH/DAY/YR) (For Identification Purposes Only) DRIVER S LICENSE NUMBER STATE PLEASE PROVIDE 7 YEARS OF ADDRESS HISTORY CURRENT ADDRESS CITY STATE ZIP YEARS MONTHS PREVIOUS ADDRESS CITY STATE ZIP YEARS MONTHS PREVIOUS ADDRESS CITY STATE ZIP YEARS MONTHS PREVIOUS ADDRESS CITY STATE ZIP YEARS MONTHS PLEASE SIGN HERE DATE The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. South Whidbey Fire/EMS Vicki Lange 360 321 1533 REQUESTING COMPANY NAME TEL SEARCH TYPE COUNTY CRIMINAL CREDIT REPORT PROFESSIONAL LICENSE SSN VALIDATION REFERENCES DRUG SCREEN: RADAR 5-Panel SSN TRACE w/ address STATEWIDE CRIMINAL DRUG SCREEN: 5/7/9-Panel 5 panel 7 panel 9 panel MOTOR VEHICLE CIVIL DRUG SCREEN: DOT 5-Panel w/mro EDUCATION FEDERAL CRIMINAL DRUG SCREEN: 5/7/9-Panel w/mro 5 panel 7 panel 9 panel EMPLOYMENT WORKER S COMP OTHER
DISCLOSURE AND AUTHORIZATION FORM South Whidbey Fire/EMS (The Company ) will procure a consumer report and/or investigative consumer report on you for employment purposes. Merchants Information Solutions, Inc. PO Box 2070, Phoenix, AZ 85001 Tel. 800-966-0576 will prepare the report. The report will contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include but are not limited to: credit reports, social security number verification, criminal records check and conviction history, court records, educational, and driving record history, verification of employment positions held, personal, professional, licensing and certification checks, drug testing results, etc. The information in the report will be obtained from private and public record sources, including, as appropriate, personal interviews with sources, such as neighbors, friends and associates. You may request more information respecting the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act will be provided to you upon request. Additional State Law Notices: If you live or are applying for a job in California, Maine, New York, Washington, Massachusetts, Minnesota or Oklahoma, please note the following: California: You may view and obtain the file maintained on you by Merchants Information Solutions, Inc. upon submitting proper identification and paying the costs of duplication services, by appearing at their offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. Maine: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports. New York: You have the right, upon written request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. All New York employers must provide a copy of Article23A of the N.Y. Correction Law to a consumer that is applying for a position in the state of New York. I am applying for a position in the state of New York. Washington State: If we request an investigative consumer report, you have the right, upon written request made within reasonable period of time, to receive from us a complete and accurate disclosure of the nature and scope of the investigation. If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. You have the right to request from the consumer reporting agency a summary of your rights and remedies under state law. Residents of, or for jobs located in, California, Massachusetts, Minnesota and Oklahoma only will be provided with a free copy of any consumer reports or investigative consumer reports on you if you check the box below. You may obtain information or copies from the Company s investigative report file at any time prior to your receipt of such copies, to the extent available, by contacting Company. I request a free copy of the report. Fair Credit Reporting Act Notification You have the right to receive a copy of your consumer credit report should one be requested for employment reasons. I request a free copy of the report. AUTHORIZATION I have carefully read and understand this Disclosure and Authorization form. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by Merchants Information Solutions, Inc. to the Company. I understand that if the Company hires me, my consent will apply throughout my employment as allowed by law. I understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports or investigative consumer reports. By my signature below, I also authorize the disclosure of information concerning my employment history, earnings history, education, credit history, credit capacity and credit standing, driving record history and standing, criminal records check and conviction history, pre-employment drug test results, and all other information deemed pertinent by the consumer reporting agency to the company by the following: my past or present employers; learning institutions, including colleges and universities; law enforcement agencies; federal, state and local courts; the military; credit reporting agencies ; and, motor vehicle records agencies. I agree that a facsimile or photocopy of this form is valid just like the original form. PLEASE FILL OUT AND SIGN BELOW LAST NAME FIRST NAME MIDDLE NAME - - SSN NUMBER PLEASE SIGN HERE DATE
South Whidbey Fire / EMS Proudly Serving Since 1950 Application Checklist ( All Items listed below must be completed before submitting the application) I carefully read through the application package, completed all required paperwork and answered all questions truthfully I have enclosed a copy of my FIRE and/or EMS certifications if applicable The application is signed, dated and notarized We have a notary on staff Monday-Friday 9:00-4:00 at the Freeland Station If you have any questions regarding the application or the process of becoming a firefighter please contact us: 360-321-1533 or ops@swfe.org Applications can be submitted two different ways Mail South Whidbey Fire / EMS 5535 Cameron Road Freeland, WA 98249 Drop off 5535 Cameron Road Freeland, WA 98249 Mon-Fri 9:00-4:00
**DRUG TESTING MUST BE DONE BEFORE THE APPLICATION IS TURNED IN** LABCORPDYNACARE 275 SE CABOT DR STE B202 OAK HARBOR, WA 98277 Phone: 360-675-5133 Fax: 360-675-4973 Hours: DRUG SCREENS 8:30AM-4:00PM CLOSED FOR LUNCH 12:30P-1:30P TESTING CAN BE DONE AT ANY LapCorp, PLEASE CHECK THEIR WEBSITE www.labcorp.com Please bring a photo ID and this number 208189