Employment Application Form

BACKGROUND CHECK REQUIREMENTS:

A Review of an individual's work and personal history will be performed to determine if a candidate is suitable for Team Membership

Types of background checks that may be conducted include:
- Academic record and verification of licenses and certifications, employment history, including references
- Criminal history,
- Child Abuse History,
- Driving record,
- A fingerprint-based criminal history report, and/or
- Other records or information related to the candidate's suitability for the position
Due to Members of Hazmat 2 Environmental Fire Rescue's involvement with hazardous materials response, under no circumstances will Hazmat 2 Environmental Fire Rescue employ, or continue to employ, an individual that has been convicted of an offense graded a felony, or its equivalent in another jurisdiction, state, territory, or country. (Reference: PEMA Directive D2010-02, XIV, (A)

Due to the Hazmat 2 Environmental Fire Rescue's involvement with firefighting and rescue operations, under no circumstances will the Hazmat 2 Environmental Fire Rescue employ, or continue to employ, an individual that has been convicted under Act 168 of 2006 amended Title 18 (Crimes and Offenses) of the Pennsylvania Consolidated Statutes, Section 2, subsection (h) (1) Arson and related offenses or any similar offense under Federal or State law. (Reference: Section 4 of the Act of November 13, 1995 (P.L. 604, No.61), known as the State Fire Commissioner Act.)
Confirm understanding of background check requirements*

I have read the background check requirementsI understand the background check requirements
Signature*

Clear

Name:*

First NameLast Name
Birth Date

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
SSN
Emergency Contact
Emergency Contact Phone
Emergency Contact Relationship
Driver's License/ ID Information
State
License Number
Photo of License / ID

Browse Files

Cancelof
How were you referred to us?*

Walk-InMemberNewspaper AdFacebookOther (please specify)
Other:
Upload Resume:

Upload a File

Cancelof
Job Skills & Training
Describe your skills:*
Training or Certifications:

Work References

Please list three (3) references that are familiar with your work life.
Work Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Reference 3
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal References

Please list three (3) references that are familiar with your personal life.
Personal Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference 3
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment History
Current or Most Recent Employer
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Start Date

MonthDayYear
Date
Still Employed?

YesNo
End Date

MonthDayYear
Date
Name of Supervisor
Reason for Leaving

Previous Employer 1
Previous Employer 1
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Start Date

MonthDayYear
Date
Still Employed?

YesNo
End Date

MonthDayYear
Date
Name of Supervisor
Reason for Leaving

Previous Employer 2
Previous Employer 2
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Start Date

MonthDayYear
Date
Still Employed?

YesNo
End Date

MonthDayYear
Date
Name of Supervisor
Reason for Leaving

Previous Employer 3
Previous Employer 3
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Start Date

MonthDayYear
Date
Still Employed?

YesNo
End Date

MonthDayYear
Date
Name of Supervisor
Reason for Leaving

Traffic and Criminal History

Note: Except as required by law (listed below), no applicant will be denied membership/employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.

Due to Members of Hazmat 2 Environmental Fire Rescue's involvement with hazardous materials response, under no circumstances will Hazmat 2 Environmental Fire Rescue employ, or continue to employ, an individual that has been convicted of an offense graded a felony, or its equivalent in another jurisdiction, state, territory, or country. (Reference: PEMA Directive D2010-02, XIV, (A)

Due to the Hazmat 2 Environmental Fire Rescue's involvement with firefighting and rescue operations under no circumstances will the Hazmat 2 Environmental Fire Rescue employ, or continue to employ, an individual that has been convicted under Act 168 of 2006 amended Title 18 (Crimes and Offenses) of the Pennsylvania Consolidated Statutes, Section 2, subsection (h) (1) Arson and related offenses or any similar offense under Federal or State law. (Reference: Section 4 of the Act of November 13, 1995 (P.L. 604, No.61), known as the State Fire Commissioner Act.)
Have you ever been convicted of a traffic offense?*

YesNo
If yes, give violation and date:
Have you ever been convicted of a criminal offense?*

YesNo
If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of thecase:

Previous Emergency Services Experience?*

YesNo
Type

Emergency ManagementEmergency Medical ServicesFireHazmatLaw EnforcementOther
Department(s) worked for

About you:
Why should you be considered for membership

0/500
Of your many strengths, which one are you most proud of, and How do you plan to use it to help grow both Hazmat 2 and yourself.*

0/500
What do you feel is a weakness of yours and how do you plan to work to over come it?*

0/500
Please verify that you are human*
Should be Empty: