Job Application - Administration

Bensenville Fire Protection District

JOB APPLICATION
Position Applying For: *

Fire Chief Executive Assistant
Available Start Date:

Month Day Year
Date
Full Name *

First Name Middle Name Last Name
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone: *

Area Code Phone Number
Cell Phone: *

Area Code Phone Number
Email Address *
Driver's License State: *
Driver's License No.: *
Social Security No. *
Birth Date *

Month Day Year
US Citizen?

Yes No
How did you learn about this job?

Education
High School
Dates Attended
Graduated

Yes No
College (Include City and State)
Dates Attended
Graduated

Yes No
College (Include City and State)
Dates Attended
Graduated

Yes No
What College Degrees have you attained?
List course work or certifications relevant to this position:

Military
Are you now or have you ever been in the military service?

Yes No
Branch of Service:
Conviction History
Have you ever been convicted of a crime other than minor traffic violations?

Yes No
List all traffic convictions and accidents you have had in the last (4) years:
Approximate Date:

Month Day Year
Date
Violation
Disposition:

Employment History
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Present Employer:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

Yes No
Previous Employer:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

Yes No
Previous Employer:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

Yes No

References
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area Code Phone Number
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area Code Phone Number
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area Code Phone Number
Please review the enclosed job description for the position for which you are applying and state whether you can perform the essential job functions listed therein with or without reasonable accommodation.
Yes No
If accommodation is needed, please explain:
Emergency Contacts
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Acknowledgement
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS AND STATEMENTS, AND I CERTIFY THAT THERE ARE NO MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS IN THIS APPLICATION, AND THAT ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS ON THIS APPLICATION OR AT ANY TIME DURING THE HIRING PROCESS MAY RESULT IN MY APPLICATION NO LONGER BEING CONSIDERED OR IN TERMINATION OF MY EMPLOYMENT WITH THE BENSENVILLE FIRE PROTECTION DISTRICT.
DATED:

Month Day Year
Date
Signature
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. This organization is committed to the policy of equal employment opportunity in recruitment, hiring, career advancement, and all other personnel practices. Your job related experience and other qualifications will be considered without discrimination on the grounds of race, color, religion, sex, national origin, age, or physical or mental handicap. All information provided in this application will be treated confidentially and will be used to help assure the best use of your abilities if you are employed with us.

If reasonable accommodation is needed for the testing process because of a disability, please notify the Board of Fire Commissioners in writing as to the specific accommodation needed.
FOR OFFICE USE ONLY
INTERVIEW DATE

Month Day Year
Date
HIRE DATE

Month Day Year
Date
TESTED IN LOYOLA SYSTEM

YES NO

Should be Empty:

Education

Military

Conviction History

Employment History

References

Emergency Contacts

Acknowledgement