Battalion Chief - Employment Application

EDUCATION
Highest level of education completed:*

Please complete the appropriate sections*

	Name & Location of School	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

***Answer ONLY if you have not completed your Bachelors degree. How many credits do you currently have completed toward your degree?
Upload your bachelors degree, click Choose File

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Upload your Fire Officer 1 credentials, click Choose File

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Upload your Structural Firefighting certification, click Choose File

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Upload your EMT or CEP credentials, click Choose File

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Upload your Incident Safety Officer credentials, click Choose File

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Upload your Fire Instructor credentials, click Choose File

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Upload your NIMS 300 & 400 credentials, click Choose File

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Upload your Wildland Firefighting certification, click Choose File

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Upload any other, click Choose File

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List any specialized training:
List equipment and/or computer software applications you are proficient in operating:

WORK HISTORY

Begin with your present or most recent employer. List all jobs, paid or volunteer, over the last ten years. Provide detail for multiple jobs with single employer. Include any experience prior to ten years ago that relates to the position. Your qualifications will be evaluated on the information provided on this application form and, if applicable, any supplemental questionnaire forms.

PLEASE NOTE: RESUMES MAY NOT BE SUBSTITUTED FOR THE REQUESTED INFORMATION.
1. Employer
Employer's Name (Most current)*
Address & location of business*
Your title*
Supervisor's name*
First and Last Name
May we contact this employer?*

YESNO
Phone number*

Area CodePhone Number
Start date*

MonthDayYear
End date

MonthDayYear
Work performed:*
Reason for leaving*
2. Employer
Employer's Name (Second most recent)
Address & location of business
Your title
May we contact this employer?

YESNO
Supervisor's name
First and Last Name
Phone number

Area CodePhone Number
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving
3. Employer
Employer's Name (Third most recent)
Address & location of business
Your title
Supervisor's name
First and Last Name
Phone number

Area CodePhone Number
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving
4. Employer
Employer's Name (Fourth most recent)
City/State where business located:
Your title
Supervisor's name
First and Last Name
Phone number

Area CodePhone Number
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving
Have you ever been terminated, discharged, or resigned in lieu of termination due to misconduct or unsatisfactory performance or service?*

YESNO
If yes, please name the employer, explain the circumstances, and date (mo/yr).

ADDITIONAL INFORMATION
List any additional information you would like us to consider:
List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)
To assist with verifying previous work experience and/or education, please list other names you have gone by:
Have you ever been convicted of, admitted committing, are awaiting trial, or been placed on probation for any crime (excluding only minor traffic violations not involving any allegation of drug or alcohol impairment)?

• You must answer YES even if the matter was later dismissed, deferred, vacated, expunged or had any other legal action taken that may have removed the matter from court records.

• If you answer YES, you must provide dates of the proceedings, the court where the proceedings occurred, a statement of the accusation against you and the final disposition of the case(s).
Note: Prior criminal history shall not automatically disqualify an individual for employment.*

YESNO
If so, provide the location, date and result/outcome for each conviction:

REFERENCES

List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.
1. Full Name*

First NameLast Name
Company*
Best phone number to reach them*

Area CodePhone Number
Years acquainted*
Email*
example@example.com
Relationship*
2. Full Name*

First NameLast Name
Company*
Best phone number to reach them*

Area CodePhone Number
Years acquainted*
Email*
example@example.com
Relationship*
3. Full Name*

First NameLast Name
Company*
Best phone number to reach them*

Area CodePhone Number
Years acquainted*
Email*
example@example.com
Relationship*

PLEASE READ THE FOLLOWING STATEMENTS AND CAREFULLY REVIEW YOUR ENTIRE APPLICATION MATERIAL BEFORE SIGNING BELOW.

• By signing this application, I certify that all statements made on this form are true and complete to the best of my knowledge. I understand that, any omission, misstatement, or falsification may be cause for rejection of this application and/or discharge from employment.

• I understand that all documents requested and/or submitted, such as, but not limited to a cover letter, resume, certifications, and reference letters, are a part of the total application packet. Failure to submit all required documents shall cause my application to be eliminated from consideration.

• I also authorize Pinetop Fire District to make all necessary and appropriate investigations allowable by law to verify the information concerning my employment.

• I understand that any offer of employment will be conditional upon the results of a criminal background investigation, social security verification, and a driver’s license check (if applicable to the position).

• I understand that any offer of employment will be conditional upon the successful completion of a drug screening test.

• I understand that my employment is at will, that the terms and benefits provided to me do not constitute any contractual relationship between myself and the District, is for no definite period of time and is terminable by myself or the District with or without notice or cause. No oral statements or representations made either before or during employment can change or modify this non-contractual and at-will relationship.

• I understand that in consideration for my employment, I agree to comply with all federal, state and local laws, as well as District policies, procedures, rules/regulations and guidelines, which may be changed from time to time.

• If employed, I authorize the District to deduct from my earnings amounts sufficient for my payments to cover any financial liability which I may incur during my employment. This may include, but not be limited to, damage to or loss of District property, group insurance premiums, tuition reimbursement, and lost tools/equipment/supplies.

• I understand that this application will remain active only for the job opening for which I have applied and will become inactive upon completion of the associated hiring process.

• I understand that it is my responsibility to keep the District advised of any changes of address and/or phone number. I have read the above, understand its content and meaning, and agree to all of its provisions.
E-Signature*

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Applicant Information Release Waiver

I voluntarily and knowingly authorize, for employment purposes only, any present or past employer or supervisor, university or institution of learning, administrator, law enforcement agency, state agency, federal agency, credit bureau, private business, military branch or the National Personnel Records Center, the Bureau of Criminal Apprehension, personal reference, and/or other persons or organizations, to give record of information they may have concerning my criminal history, motor vehicle history, earnings history and employment records, general reputation, character, and any other information requested to Pinetop Fire District and/or its agents or representatives. I understand that, if hired, my consent will apply throughout my employment with the District.
You must agree to accept the terms of the document in order to submit an application.
By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree
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Pinetp Fire District

1845 S. Pine Lake Rd

Pinetop, AZ 85935

Phone: (928) 367-2199, Fax: (928) 367-2220

Email: jobs@pinetopfire.com