Jeffersontown Fire & EMS Application

APPLICATION FOR EMPLOYMENT
JEFFERSONTOWN FIRE & EMS
Name*
Date*

MonthDayYear
Date
Please indicate the position(s) for which you wish to be considered. We are required to consider Applicants for the specific position they apply. (do not list "any")
1.*
2.
3.

APPLICATION FOR EMPLOYMENT
DATE*

MonthDayYear
Date
POSITION APPLIED FOR*
Referred by
Date Available for Work*

MonthDayYear
Date
INSTRUCTIONS: Please read carefully. Every item on this form must be answered to the best of your ability. Please print in ink. Your qualifications will be carefully reviewed and you will be given thorough consideration for the position(s) for which you have applied. Upon employment, this application will become part of your permanent record at Jeffersontown Fire Protection District. Keep this in mind as you complete it. Special Note: You are not required to supply any information that is prohibited by Federal, State, or Local law. We are an Equal Opportunity Employer. Jeffersontown Fire Protection District does not discriminate on the basis of race, color, religion, gender, national origin, pregnancy. marital status, citizenship. age. disability, veteran status, gender orientation/identify, gender preference, or any other legally protected class. You may request assistance in completing this application.
PERSONAL
Name*
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Address*

Street Address

Apt #/Box

CityState / Province

Postal / Zip Code
Email*
example@example.com
If younger than 18, state your age here
Are you legally entitled to work in the United States?***

YesNo
**Compliance with I-9 requirements is mandatory, upon employment
If a job offer is made to you, we will conduct a criminal record check of felony convictions. Check the box to indicate that you understand we may withdraw the job offer if the criminal record check is unfavorable.*

I understand
Have you ever been convicted of a moving traffic violation?*

YesNo
If yes above, list all here
Have your driving privileges ever been revoked or suspended?*

YesNo
If yes above, list here when and why:
Do you currently hold a Commericial driving license?*

YesNo

EDUCATION
Did you graduate from High School? College or university (Name and location) College or university (Name and location) Please initial here to certify that your college degree was earned through the actual completion of college level course work and conferred by an accredited college or university where you completed your coursework. Did you graduate?If no. number of hours completed Degree Grade Point Average MajorMinor If attending. date of graduation Other Education
Did you graduate from High School?*
If no, last grade completed:
Grade Average
College or university (Name and location)
College or university (Name and location)
Please INITIAL here to certify that your degree was earned through the actual completion of college level course work and conferred by an accredited college or university where you completed your coursework.

Clear
INITIAL HERE
Did you graduate?
If no, number of hours completed
Grade Point Average
Degree
Major
Minor
If currently attending, expected date of graduation

MonthDayYear
Date
Other Education*
If none, type N/A or None
License(s). including the state of issue and the number*
If none, type N/A or None

MILITARY
Check here if military is not applicable.

Not Applicable
List service in U.S. Military:
From
to
Branch
Rank at Discharge
Military experience that may be applicable to working here:
If none, type N/A or None

In the following space, please describe any special knowledge, skills, or abilities that will bring added value if you are employed here.
Please list the name, address and contact information of three references who can attest to your knowledge, skill and ability to perform the work for which you are applying. We are seeking business related references, not personal references.
Name*
Phone Number*
Please enter a valid phone number.
Employer*
Location*
Position*
Name*
Phone Number*
Please enter a valid phone number.
Employer*
Location*
Position*
Name*
Phone Number*
Please enter a valid phone number.
Employer*
Location*
Position*

Drivers License - Please upload a picture/copy of your current drivers license.

Cancelof
If you are unable to upload a current copy of your drivers license please bring a copy to our headquarters at 10540 Watterson Trail, Jeffersontown, KY 40299 or email cthomas@jeffersontownfire.com.

CONDITIONS OF EMPLOYMENT
1. The facts as stated on this application are true and correct. I understand that, if employed, false statements on this application may cause my immediate dismissal.
2. I authorize whatever background and personal reports needed to verify that the information I have supplied is true and accurate and to determine my fitness for this job and hold harmless those who have the responsibility to develop such a report. A copy of this authorization is as valid as the original.
3. I understand that I may be required to work overtime as a condition of being employed.
4. In consideration of my employment, I agree to conform to the rules and regulations for employees. I understand I am subject to the terms of KRS Chapter 75 and that this application is not a contract of employment with Jeffersontown Fire Protection District and that my employment and compensation can be terminated, at the option of either Jeffersontown Fire Protection District or me in compliance with KRS Chapter 75. I understand that no representative of Jeffersontown Fire Protection District. has any authority to enter into any verbal agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and that no document, policy or practice of Jeffersontown Fire Protection District, may change the foregoing.
5. I understand that I will be required to submit to a pre-employment, and/or post-employment test to establish my fitness and substance free status, if not prohibited by law.
6. Upon separation of employment. I authorize Jeffersontown Fire Protection District to withhold from my final paycheck any monies owed by me (if not prohibited by law) for equipment. loans, products, services, uniforms unreturned. benefits advanced that I have not earned. materials, or other assets in my possession not promptly returned or repaid as agreed.
DATE*

MonthDayYear
Date
SIGNATURE*

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Should be Empty:

	Select for Anytime	Start TIme	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

APPLICATION FOR EMPLOYMENT

JEFFERSONTOWN FIRE & EMS

APPLICATION FOR EMPLOYMENT

PERSONAL

EDUCATION

MILITARY

GENERAL EMPLOYMENT INFORMATION

EXPERIENCE

CONDITIONS OF EMPLOYMENT