WFD Application

	Date of Conviction, Court, Offense Charged, Sentence Imposed
1
2
3
4

	For each entry include the Date Earned and Expiration Date, if applicable:
1
2
3
4

	Reference Full Name, Relationship to you and their Phone Number
1
2
3

Employment History

List your employment history beginning with your current or most recent employment.
EMPLOYER
Phone Number
Please enter a valid phone number.
From

MonthDayYear
Start Date
To

MonthDayYear
Leave blank if not leaving current employer.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
May we contact?

YesNo
JOB TITLE
Example: Firefighter, EO, etc.
DUTIES
Reason for Leaving
If not leaving current employer, enter N/A.
EMPLOYER
Phone Number
Please enter a valid phone number.
From

MonthDayYear
Start Date
To

MonthDayYear
Leave blank if not leaving current employer.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
May we contact?

YesNo
JOB TITLE
DUTIES
Reason for Leaving
If not leaving current employer, enter N/A.
EMPLOYER
Phone Number
Please enter a valid phone number.
From

MonthDayYear
Start Date
To

MonthDayYear
Leave blank if not leaving current employer.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
May we contact?

YesNo
JOB TITLE
DUTIES
Reason for leaving
If not leaving current employer, enter N/A.
EMPLOYER
Phone Number
Please enter a valid phone number.
From

MonthDayYear
Start Date
To

MonthDayYear
Leave blank if not leaving current employer.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
May we contact?

YesNo
JOB TITLE
DUTIES
Reason for leaving
If not leaving current employer, enter N/A.

Conditions of Employment Statement
I certify that the information I have provided on my application is complete and accurate and give Westfield Fire Department the right to investigate all information given and to secure additional appropriate information if necessary. In accordance with the law and my understanding of this statement, I authorize my current and former employers to give any information regarding my employment and hereby release from all liability all persons, companies or corporations furnishing such information in good faith.

I understand and acknowledge that any employment relationship with Westfield Fire Department is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. Additionally, the completed application is not a contract or guarantee of employment.

I further understand that any misleading or incorrect statements or the failure to complete any part of this application not prohibited by law may render this application void and if employed, could be cause for immediate discharge. Also, I understand that if employed I would be required to abide by all rules and regulations of the Employer.
APPLICANT PRINT NAME
DATE

MonthDayYear
Date
Applicant's Signature*

Clear
Once you submit your application, you will be given the option of downloading a copy or having a copy emailed to you.
Should be Empty: