APPLICATION FOR PART TIME EMPLOYMENT

Sharpsburg Fire Prevention Association, Inc.

300 Taylor Dr

P. O. Box 275

Sharpsburg, NC 27878

Telephone: (252) 977-1236

Fax: (252) 977-0921
APPLICATION FOR PART TIME EMPLOYMENT
Name*
Date of Application *
Street Address*
Mailing Address (if different)*
City*
State*
Zip Code*
Social Security No.*
NC Driver’s License No.*
Date of Birth*

MonthDayYear
Date
Telephone:
(Home)*
(Work)*
(Cell)*
Please list your current employer. If unemployed, list most recent employer.
Current Employer*
Phone No.*
Please list two emergency contacts:
Name*
Relationship*
Phone No.*
Name*
Relationship*
Phone No.*
Do you currently hold any of the following certifications? If so, please provide the appropriate documentation at the end of this form.*

North Carolina Class B Driver LicenseNorth Carolina Fire & Rescue Commission Level I Firefighter - CertificationNorth Carolina Fire & Rescue Commission Level II Firefighter - CertificationNorth Carolina Fire & Rescue Commission Driver/ Operator - CertificationNorth Carolina Fire & Rescue Commission Level I Instructor – CertificationNorth Carolina Fire & Rescue Commission Level II Instructor – CertificationNorth Carolina Hazardous Material Responder- Level I (Operations Level)North Carolina Medical Responder (or) County First Responder LevelNorth Carolina Emergency Medical Technician- Basic - CertificationNorth Carolina Emergency Medical Technician- Intermediate - CertificationNorth Carolina Emergency Medical Technician- Paramedic - Certification
List any previous relevant experience or training*
How would you rate your health status?*

ExcellentGoodFairPoor
Are you currently suffering from or have a history of any medical conditions that may affect your performance as a firefighter?*

YesNo
If yes, explain*
Are you aware of any allergies of medication that would be important information for care providers in the case of a medical emergency?*

YesNo
If, yes explain.*
List each state/county you have lived in within the past ten (10) years*
List any criminal convictions*
List any traffic convictions in the past seven years*
Are there special circumstances related to convictions listed in above questions which you would like us to consider? (NOTE- criminal and traffic convictions will be considered on a case by case basis and do not automatically disqualify you for employment)*
** By signing this application as a part time firefighter, I acknowledge that I will be required to obtain a physical and a drug test by a determined physician at the cost of the Department.

** I hereby certify that there are no willful misrepresentations of falsifications of my statements and answers to listed questions. I am aware that, should an investigation disclose such misrepresentation or falsification, my application will be rejected.

** I do hereby certify that if accepted for employment of the Sharpsburg Fire Prevention Association, Inc. I will abide by the By-Laws of the Association and any other Policies and Regulations of the Department.
Signature*

Clear
Date*

MonthDayYear
Date
Printed Name*
AUTHORIZATION FOR RELEASE OF RECORDS
I,
(Your Name)*
do hereby authorize any military organization, law enforcement agency, physician or other medical personnel, insurance agencies, banks and credit agencies, former and present employers, or other individuals to furnish to the Sharpsburg Fire Prevention Association, Inc. (“the Department”) or its authorized agent all available information. I hereby release any of the above from any and all civil or criminal liability whatsoever for providing this information.
AUTHORIZATION FOR CONSUMER REPORT

I understand and acknowledge that I am applying for employment with the Sharpsburg Fire Prevention Association, Inc. (“the Department”). In connection with that application, I expressly authorize the Department to conduct a full background check and to obtain a Consumer Report and/or an investigative report about me, including but not limited to, a criminal record check and/or credit report. I further understand and acknowledge that if I am accepted as an employee, this authorization shall remain on file and shall serve as an on-going authorization for the Department to obtain such reports at any time during my employment. I acknowledge that I have received a copy of the attached “Fair Credit Reporting Act Disclosure” and “a Summary of Your Rights Under the Fair Credit Reporting Act” prior to executing this authorization.
Signature*

Clear
Printed Name*
Date*

MonthDayYear
Date
Certifications and other attachments.*

Cancelof
Should be Empty:

APPLICATION FOR PART TIME EMPLOYMENT

AUTHORIZATION FOR RELEASE OF RECORDS

AUTHORIZATION FOR CONSUMER REPORT