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Springdale Fire Protection District |
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Honor Service Integrity |
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Position(s) Applied for………………………………. Available Not Available
Other Positions considered for ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________
Hired.............................................................................. Yes No Date of Hire ________/_______/________
Position Hired for ________________________________________________________________
NOTES__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Completed by ________________________________ Date _____/____/_____
Voluntary Affirmative Action Information (Completion of information below is voluntary)
Date ____/____/____
Position(s) applied for ___________________________________________________________
Advertisement Employee Relative Walk-in Other
Name of Source (if Applicable) ____________________________________________________
Applicants Name _________________________________________________(___)__________ Last First Middle Area Code Phone Applicants Address______________________________________________________________ Street City State Zip Code As required, we comply with government regulations including Affirmative Action obligations where they apply.
In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.
Please be advised that your survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Check one…………………………………………………………………………………….. Male Female
Check one of the following Race/Ethnic Group Hispanic Black White American Indian/Alaskan Native Asian/Pacific Islander
SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VERTERANS AND INDIVIDALS WITH PHYSICAL OR MENTAL HANDICAPS OR DISABILITIES:
Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and qualified handicapped individuals.
You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.
IF YOU SO WISH TO BE IDENTIFIED, PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:
VIETNAM ERA VETERAN DISABLED VETERAN INDIVIDUAL WITH A DISABILITY
To be completed by applicant – Not for interview purposes – To be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation
Springdale Fire Protection District 1771 Springdale Blvd. Fenton, MO 63026 Phone (636) 343-9300 Fax (636) 305-1414
Physicians Release Form
Name: ______________________________ SSN: ____________________________________
Sex: M F Date of birth: __________________ Phone: ___________________________ month day year I understand that this physicians release form is for the purpose of qualifying my abilities to perform as a fire fighter for the Springdale Fire Protection District. It is not meant to be a determining factor with regard to acceptance as a member of the District, but to gauge my overall physical abilities to perform certain tasks. I further understand that factors beyond the control of the Springdale Fire Protection District and the physician completing this form may affect my physical abilities to perform, which were not distinguishable at the time that this form was completed. I hereby release the Springdale Fire Protection District and the physician named on this form from any and all liability with regard to it’s content.
___________________________________________ _______________________________ signature of applicant date
(please read the paragraph below and complete the form - please note any limitations in the comments section)
The position of fire fighter requires the applicant to exert large amounts of energy in a short period of time. This exertion can be expected in high temperatures exceeding 1000°. Fire fighters are protected from this heat with protective garments and self contained breathing apparatus weighing approximately forty pounds. Activities while working include climbing ladders, working overhead, crawling, bending, standing, lifting, carrying, pushing, pulling and operating power tools and motor vehicles.
I _______________________________ have evaluated the above named applicant and release Physicians name (please print)
him/her to participate as a fire fighter with the Springdale Fire Protection District with the
following limitations. Comments: __________________________________________________
______________________________________________________________________________
__________________________________________ ______________ ________________ Signature of physician date phone
Springdale Fire Protection District 1771 Springdale Blvd. Fenton, MO 63026 Phone (636) 343-9300 Fax (636) 305-1414
Applicant Authorization and Consent for Release and Disclosure of Information
We welcome your application with the Springdale Fire Protection District (hereinafter referred to as the “District”). We are proud that our success is the result of the quality and caliber of our establishment. You are applying for a position whose acceptance will place you in a category of recognized professionals. In pursuit of that excellence, we require, as a condition of membership or employment and/or continued membership or employment, all applicants consent to and authorize a pre-screening of the background information submitted on their applications and resumes.
I authorize the District and Pre-Employment Screening Inc., a consumer reporting agency, to retrieve information from all previous employers work history, education institutions, governmental agencies, law enforcement agencies at the federal, state and county level, agencies or individuals, relating to my past activities, to supply information concerning but not limited to previous employment, education, motor vehicle, social security and criminal background checks. I understand that the consumer report may be prepared summarizing this information.
I authorize Pre-Employment Screening Inc. of St. Louis, Missouri (hereinafter referred to as “PES”), and any of its agents/designated representatives, to disclose orally, electronically, and in writing the results of its verification process and/or interview to the designated authorized representatives of the District.
I do hereby forever discharge the District, its agents, PES, and its associates to the full extent permitted by the law from damages, losses, liabilities, costs and expenses, or other charge of complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if adverse action is taken based on information attained by the District and to receive, orally, written or electronically, a copy of the consumer report and a description of the rights of a consumer.
I do hereby certify that all of the statements and answers set forth on the application form and on my resume are true and complete to the best of my knowledge, and I understand that if subsequent to membership or employment any such statements and/or answers are found false or that information has been omitted, such false statements or omissions will be just cause for the termination of my position.
“Note: The following information is provided voluntarily and is not as part of your application for employment. It is used for identification purposes in verifying background verifications”.
________________________________ _______________________________ Printed name SSN #
_______________________________ ______________________ ______________________ Signature Date of birth Date
_______________________________ ______________________ ______________________ Driver’s license number State issued Expiration date
_____________________________________________________________________________________ List any cities and/or states, which you have lived *Springdale Fire Protection District is an Equal Opportunity Entity Springdale Fire Protection District 1771 Springdale Blvd. Fenton, MO 63026 Phone (636) 343-9300 Fax (636) 305-1414
Disclosure
This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in section 604(b) to the applicant that previous employment, education, social security, motor vehicle report and a criminal background check may be obtained for the purpose of membership and/or employment only.
By the signature below, the applicant acknowledges that Springdale Fire Protection District has made this disclosure.
_______________ ________________________________ Date Signature
________________________________ Print name (last, first, middle) |
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Highlight the Application below and return to Station 1 with a copy of certificates |