North Berkeley Fire District Application

EMPLOYMENT APPLICATION
Specify Position Applying For
Full Name
Street Address
Phone Number
Driver's License No./State
E mail Address
example@example.com
If under 18, list date of birth

MonthDayYear
Date
NOTHING IN THIS APPLICATION OF IN ANY OF THE RELATED DOCUMENTS CONSTITUTES A CONTRACT OF EMPLOYMENT AND ALL EMPLOYEES OF THE TOWN ARE EMPLOYEES-AT-WILL WHO MAY QUIT AT ANY TIME FOR ANY REASON AND WHO MAY BE TERMINATED AT ANY TIME FOR ANY OR NO REASON. NO ONE OTHER THAN THE MAYOR MAY MAKE ANY PROMISES OR ASSURANCES OR ENTER INTO ANY CONTRACT WHETHER ORAL OR WRITTEN, THAT IN ANY WAY IS CONTRARY TO OR INCONSISTENT WITH THE LIMITATIONS SET FORTH IN THIS PARAGRAPH, AND ANY SUCH PROMISES, ASSURANCES, OR PURPORTED CONTRACTS SHALL BE INVALID AND NOT BINDING ON THE TOWN UNLESS ADOPTED, ENDORSED, OR AGREED TO IN WRITING BY THE MAYOR.
Have you ever attended school under a different name?
YesNo
Please Specify
Have you applied here before?

No.
If yes give dates

MonthDayYear
Date
Do you have any family members that are employed and/or elected or appointed by the Town of St. Stephen?
Yes
No.
If yes, please list names and positions of family members currently employed:
Have you worked for us before?

No.
If Yes, specify dates and positions

MonthDayYear
Date
Position
List any special skills you have, equipment you operate, or licenses you have obtained such as the commercial driver's license
Certification

Fire Fighter 1 or equivalent
Fire fighter 2 or equivalent
EVDT
Pump Ops 1 or higher
First Aid/Cpr
ICS 100 , 200 , 700 , 800
ICS 300, 400
Other
List specific computer skills to include hardware and software programs
Have you ever served as a member of the armed forces?

YesNo
If Yes, please list branch, occupation, duties, dates of service; submit a copy of your DD 214

MonthDayYear
Date
Branch and Duties?
Convicted of a crime other than a minor traffic violation?
YesNo
If Yes, list all dates and nature of offenses

MonthDayYear
Date
Nature of Offenses
NOTE : A yes answer to any of the above questions does Not automatically disqualify you from employment.
Type of Employment Desired :

Part TimeVolunteer
Start Date

MonthDayYear
Date
Salaried Desired
If hired are you available to work "on call" status if required and/or the required hours and shifts for the position?
YesNo.
If No, please explain
May we contact your past employer(s)?

YesNo
May we contact your current employer?

YesNo
List three persons, not related to you, whom you have known for at least one year.
Ex. Name-Phone-Address
List your last four employers, beginning with your current or most recent first.
Ex. Employer-Dates-Reason for Leaving
SIGNATURE AND CERTIFICATION
PLEASE READ CAREFULLY BEFORE YOU SIGN!

I understand further that all information contained in this application may be verified through third parties, including schools and prior employers. By signing this application, I affirm that all information in this application is true and complete, and I understand that any misrepresentation, falsification, or omission is sufficient reason for dismissal or refusal of employment.

I understand that, if hired, my employment with the Town will be at will, meaning I can quit at any time for

any or no reason and I can be discharged at any time for any or no reason. I understand that this application

and related documents do not constitute a contract of employment.
Date

MonthDayYear
Date
Signature

Clear
The Town of St. Stephen is an EQUAL OPPORTUNITY EMPLOYER. We adhere to a policy of making all employment decisions without regard to race, color, religion, sex, national origin, age disability, or political affiliation, except where age is a bonafide occupational qualification.
Authorization for Release of Information
TO:
Any Academic Dean, Registrar, Principal, Guidance Counselor, other authorized person at a school (college, business, trade or high school), or Town of St. Stephen

Any past or present Employer, or Town of St. Stephen

I, First Name Last Name am aware that my entire background, to include a criminal background check, is to be investigated and hereby authorize and request the release of any and all information you have concerning me, excluding health care information, to the Human Resource Office for the Town of St. Stephen as my authorized representative for the purpose of obtaining this information.

I, hereby release anyone addressed above, who gives information about me in the course of an investigation covered by this authorization, from any liability for damages of whatever kind to me, my family, heirs or associates as a result of giving such information, except that I do not release anyone who gives information that he or she knows is false, deliberately intending to harm me.
Print Name
SSN
Date of Birth

MonthDayYear
Date
Driver's License No./State
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of
County of
Date

MonthDayYear
Date
Signature

Clear
APPLICANT DATA RECORD
THE TOWN OF ST. STEPHEN'S POLICY IS TO COMPLY WITH ALL LAWS INCLUDING THOSE BANNING DISCRIMINATION. APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT

REGARD TO RACE, COLOR, NATIONAL ORIGIN, RELIGION, AGE, SEX, VETERAN STATUS OR DISABILITY.

NAME (as is appears on Social Security card):
How did you hear about this job?

WebsiteFacebookTown Employee
CHECK ONE:

Black or African-AmericanWhiteNative Hawaiian/Pacific IslanderAmerican Indian/Alaskan NativeAsianOther
PLEASE COMPLETE THE APPLICANT DATA RECORD. IT WILL BE KEPT IN A CONFIDENTIAL FILE SEPARATE FROM THE APPLICATION FOR EMPLOYMENT. WE APPRECIATE YOUR COOPERATION.AS EMPLOYERS / GOVERNMENT CONTRACTORS, WE COMPLY WITH GOVERNMENT REGULATIONS AND AFFIRMATIVE ACTION RESPONSIBILITIES. SOLEY TO HELP US COMPLY WITH GOVERNMENT RECORD KEEPING, REPORTING AND OTHER LEGAL REQUIREMENTS,
Should be Empty:

EMPLOYMENT APPLICATION

SIGNATURE AND CERTIFICATION

APPLICANT DATA RECORD