Application for Employment

Form

Application for Employment
This application is not an employment contract but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, mental status, national origin, citizenship, disability, veteran status, or any status protected under state and federal law. It is also the policy of the company to have the option of conducting pre-employment screenings before a job offer is made. Employment may be contingent upon the successful completion of a medical examination which may include providing body substance samples and the successful completion of an agility test.
Date

MonthDayYear
Date
Personal Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you at least 18 years of age

YesNo
Are you legally eligible to accept employment in the United States

YesNo
Employment Desired
Start Date
Have you had a Fire Department Physical in the last 12 Months?

YesNo
Have you worked here before ?

YesNo
Have you ever applied here before?

YesNo
Have you ever been discharged or asked to resign from a job?

YesNo
If yes to above question please explan
Qualifications do you possess?

1154 NFPA FF21153 NFPA FF1Emergency Medical ResponderEMT2722 Hazmat ops1210 EVDT
Other SCFA/FEMA classes
Education:
High School
Gradated

Yes
Number of Years Attended
College
Number of Years Attended
Graduated

Yes
Areas of Study
Other School
Work Experience

Describe all work experience (paid and unpaid) starting with the most recent
Current Employment
Name of Current Employer or NONE if not Employed
Position
Salary
Reason for Leaving
Date Started / Dated Ending
Previous Employment 1
Name of Previous or NONE if not Employed
Salary
Date Started / Date Ending
Position
Reason for Leaving ?
Previous Employment 2
Name of Previous or NONE if not Employed
Position
Reason for Leaving ?
Date Started / Date Ending
e.g 01/01/1999 / 01/01/2000
Previous Employment 3
Name of Previous or NONE if not Employed
Position
Reason for Leaving ?
Date Started / Date Ending
References 1: Name
Phone Number
Please enter a valid phone number.
Years Acquainted
Relationship
References 2: Name
Phone Number
Please enter a valid phone number.
Years Acquainted
Relationship
References 3: Name
Phone Number
Please enter a valid phone number.
Years Acquainted
Relationship
References 4: Name
Phone Number
Please enter a valid phone number.
Years Acquainted
Relationship
SCDLLR Firefighter Registration Information

Name Based Criminal Records Check Request Additional Information. The South Carolina Firefighters Employment and Registration Act requires a criminal records check prior to employment of a paid or volunteer firefighter. No later than 60 days after the start of his or her employment date as a paid or volunteer firefighter, each firefighter must be registered with the Office of State Fire Marshal (OSFM) by his or her Fire Chief or other employer. The criminal background check must be conducted before registration. After June 30, 2001, a person may not perform firefighting duties in South Carolina if person has been convicted of, or pled guilty to, or pled nolo contendere to (a) aa felony; (b) arson or another offense provided in Article 3, Chapter 11 Title 16; or (c) an offense involving a controlled substance as provided for in chapter 53 of Title 44. The prohibition applies for 10 years after the conviction or plea of guilty or noloncontendere.
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Date of Birth*

MonthDayYear
Birth Date
Social Security Number*
Driver's License Number and State*
DL # and State of Issue
Name*

First NameMiddle NameLast Name
Name Aliases

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Form

Education:

Work Experience