NORTHERN UNION COUNTY JOINT FIRE & EMS DISTRICT

Northern Union County Joint Fire & EMS District
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Education And Training
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Please use the following space to provide any further information on training, education, skills, abilities, hobbies, volunteer work, ETC, That you possess or have experienced that may be helpful in the evaluation of your application.
Personal Information Continued
Do you have any commitments (IE Second job, School, ETC.) Which might interfere with, or adversely affect, your employment should we select you for a position?

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If Yes, Please Explain
Do you possess a valid Drivers License?

YesNo
If No Can you obtain one prior to employment?

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Are you Eligible to work in the United States?

YesNo
Are you a resident of Ohio?

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If not, are you willing to become a resident upon employment?

YesNo
List at Least 3 References
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Reference 2 Address

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PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. INDICATEYOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONSOF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACHPARAGRAPH. IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS,CONTACT THE EMPLOYER BEFORE INITIALING THE PARAGRAPH.
1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol or substance abuse testing. 2. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded. 3. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity. 4. I hereby authorize the employers, schools and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic and other records to the employer.
Initials
I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THISEMPLOYMENT APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THEBEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALLSTATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THATANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATIONPROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER ORTERMINATION FOLLOWING EMPLOYMENT.I ALSO RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYERWILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUGUSE, OR ALCOHOL ABUSE.FINALLY, I AGREE THAT ANY CLAIM OR LAWSUIT RELATING TO MYSERVICE WITH THE NORTHERN UNION COUNTY JOINT FIRE AND EMSDISTRICT MUST BE FILED NO MORE THAN SIX (6) MONTHS AFTER THEDATE OF THE EMPLOYMENT ACTION THAT IS THE SUBJECT TO THE CLAIMOR LAWSUIT. I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.
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Northern Union County Joint Fire & EMS District

Current Employment

Previous Employment

Education And Training

Personal Information Continued

List at Least 3 References