Application For Employment

Name*

First Name MILast Name

Address*

Email*

example@example.com

Home Phone

Work Phone

Cell Phone*

Birth Date*

Date

Social Security Number

Are you a resident of Westfield Township or Village?*

Are you a resident of Medina County?*

How many miles from the Fire Station do you live?*

Are you an Ohio State Certified Firefighter or EMT?*

If you are certified, please list what certifications you have:

Do you possess a Valid Ohio Drivers License?*

Driver License Number

Driver License Expiration Date

Spouses Name

Phone #

Children Names Ages

Address if different than your own

Current Employer

Phone#

Address

Job Title

Supervisor

Previous Employer

Phone#

Address

Job Title

Reason for Leaving

Emergency Services Experience

Agency

Phone #

Address

Rank Title Function

Share with us your interests hobbies goals

References

Name*

Phone

Association

Name*

Phone

Association

Name*

Phone

Association

Please Read the following Before Signing Below. I understand that Westfield Fire & Rescue will rely on the truthfulness, accuracy, and completeness of the information furnished by me in this application and during any interview of me. Any misleading, incorrect, or incomplete statements by me, made intentionally or otherwise, may be considered cause for rejection of this application, or, if am subsequently employed by Westfield Fire & Rescue, suspension, or termination of my employment.

If I become employed by Westfield Fire &Rescue. I agree to conform to all the rules and regulations of Westfield Fire & Rescue, Westfield Township, and The Village of Westfield Center as they exist and asthey may be amended in the future. I understand and agree that my employment with Westfield Fire & Rescue can be terminated, with or without cause, and with or without notice, at anytime at the option of the Westfield Fire & Rescue Fire Committee, Westfield Township Trustees, Village of Westfield Center Council, or myself.

Authorization to Obtain Background Information In connection with my application for employment with Westfield Fire & Rescue, and toenable Westfield Fire & Rescue to verify information I have already voluntarily given to Westfield Fire & Rescue in an Application for Employment, I hereby authorize Westfield Fire & Rescue, its employees, or agents to conduct a background investigation on me. I understand and agree that this investigation may include, among other things, investigative consumer reports, criminal reports, driving reports, reports on past and present employment, school transcripts, and othertypes of reports, and that such reports may reveal information about my character, general reputation, personal conduct, mode of living, school performance, work performance, work habits, claims involving insurance companies, and reasons for termination of past employment involving other employers or Emergency Service Providers.

If am hired by Westfield Fire & Rescue, I hereby authorize Westfield Fire & Rescue, and its employees and agents to obtain consumer reports, including investigative consumer reports, concerning me for purposes of evaluating me for promotion, reassignment, or retention as an employee, or any other employment related pu1 posc, at any time throughout the duration of my employment with Westfield Fire and Rescue.

I further understand that if I am hired, this authorization shall remain in effect and shall serve ns ongoing authorization for Westfield Fire & Rescue to procure consumer reports, including investigative consumer reports, for lawful purposes at any time during my employment with Westfield Fire & Rescue.

Further, 1 understand and agree that Westfield Fire & Rescue, its employees, or agents may and will be requesting information from various federal, state, and other agencies which maintain records concerning driving, criminal, civil, scholastic, and other experiences, and claims involving insurance companies.

Iauthorize, without reservation, any party or agency contacted by Westfield Fire & Rescue, its employees, or agents, to falsify the above-mentioned information, and to provide copies of records, and school transcripts as requested by Westfield Fire & Rescue. Some states require that I be given notice regarding disclosure of disciplinary action taken against me as an employee. In order to be considered for employment with Westfield Fire & Rescue, I hereby waive a 11y such notice.

By signing below, I certify that1 have received a copy of Consumer Report Disclosure Form and I have read the foregoing, and that I understand and agree with the statements these documents set forth.

Current Address*

Please Print Full Name*

Social Security Number*

Signature*

Date*

Date

WESTFIELD FIRE & RESCUE