MMPW Employment Application

Online Employment Application

M.M.P.&W VOLUNTEER FIRE & AMBULANCE COMPANY
M.M.P.&W Volunteer Fire & Ambulance Company (MMP&W FD) considers applications for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, citizenship or any other characteristic protected by law.
PERSONAL INFORMATION
Name*

First NameLast Name
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please provide your best contact number
Are you at least 20 years old?*

YESNO
When are you available to start?*

MonthDayYear
Date
How did you hear about the position?*
Do you have any relatives/friends working or volunteering here?*

NOYES
If YES, please list the names:
POSITION INFORMATION
Please select the position you are applying for:*

EMT OnlyFull-Time Firefighter/EMTPart-Time Firefighter/EMT
Have you ever worked/volunteered for this organization?*

NOYES
If YES, please list the dates and reason for leaving.
LEAVE BLANK IF YOU NEVER WORKED/VOLUNTEERED FOR MMP&W.
CERTIFICATION INFORMATION

(Photocopies are required at the in-person interview)

Please list current certifications only:

	Certification Number	Expiration Date	Issuing Angency
CPR
EMT/EMT-P
Firefighter 1&2
NIMS
Vehicle Rescue
EVOC/EVDT
HAZMAT Ops
Pumps 1 & 2
Other:
Other:

WORK REQUIREMENTS & GENERAL INFORMATION
Can you provide proof, if hired, that you are eligible to work in the US:*

YESNO
Driver’s License Number:*
Driver’s License State:*
List all moving violations (convictions) and accidents in the last five years:
Have you you ever been convicted, pled guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended?*

NOYES
If YES, explain:
A conviction will not necessarily disqualify you from employment.
Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid?*

NOYES
If YES, explain:
EMPLOYMENT HISTORY

List your last three employers or volunteer activities, starting with the most recent:
1. EMPLOYER (most recent)*
Business/Company Name
Job Title:*
Supervisor:*
Start Date

MonthDayYear
Date
End Date:

MonthDayYear
Date
Job Description:*
PLEASE INCLUDE DUTIES AND RESPONSIBILITIES
Employer's Telephone Number:
May we contact this employer?

YESNO
Reason for leaving:
2. Employer
Business/Company Name
Job Title:
Supervisor:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Job Description:
PLEASE INCLUDE DUTIES AND RESPONSIBILITIES
Employer's Telephone Number:
May we contact this employer?

YESNO
Reason for leaving:
3. Employer
Business/Company Name
Job Title:
Supervisor:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Job Description:
PLEASE INCLUDE DUTIES AND RESPONSIBILITIES
Employer's Telephone Number:
May we contact this employer?

YESNO
Reason for leaving:

MILITARY SERVICE

	BRANCH OF SERVICE	DATE BEGAN	DATE ENDED	RANK	LOCATION
If Applicable:

PAST EMPLOYMENT
Have you ever been placed on probation or terminated for excessive absenteeism?*

NOYES
Have you ever been disciplined or fired for insubordination?*

NOYES
Have you ever been disciplined or fired for violation of safety rules?*

NOYES
Have you ever been disciplined or fired for assault or fighting?*

NOYES
Have you ever been disciplined or fired for harassment?*

NOYES
Have you ever been disciplined or fired for patient abuse?*

NOYES
Have you ever been disciplined or fired for alcohol or drug related activity at work?*

NOYES
If you answered YES to any question above, please explain:
Answers of Yes for any of the above questions will not necessarily disqualify you from employment.
EDUCATION AND TRAINING
HIGH SCHOOL:*
Years Completed*

All Four YearsThree YearsTwo YearsOne Year
Did you graduate High School?*

YESNO
If you did not graduate, did you receive your GED?

YESNO
COLLEGE:
Name of School
Number of Years Completed:
Did you graduate?

YESNO
Degree:
Major:
Minor:
TECHNICAL/OTHER SCHOOLING:
Number of Years Completed:
Main Course of Study:
Certificates/Awards:
Certificates/License:
Describe any additional qualifications/training, professional affiliations, or information, personal or professional, that you feel would be beneficial for us to know when considering your application (must provide proof of all certifications/training):
Feel free to upload your certifications: (if applicable)

Cancelof
REFERENCES
List three persons, other than relatives, who have knowledge of your work experience and/or education.
1. Name

First NameLast Name
Their Occupation:
Years Known:
Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
Their Occupation:
Years Known:
Phone Number
Please enter a valid phone number.
3. Name

First NameLast Name
Their Occupation:
Years Known:
Phone Number
Please enter a valid phone number.
List two personal references that have known you for at least three years outside work.
1. Name

First NameLast Name
How they know you:
Years Known:
Phone Number
Please enter a valid phone number.
2. Name

First NameLast Name
How they know you:
Years Known:
Phone Number
Please enter a valid phone number.
ACKNOWLEDGEMENT

PLEASE READ AND SIGN
I certify that the information I have given on this application is true, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or the company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment.

If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties.

I understand that I may be required to undergo drug-screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be
required by the company as a condition of my employment, and I hereby give my consent to the release of all information which the company deems necessary to determine my ability to perform job duties now or in the future.

I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from this company.

I hereby authorize the company to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, credit history and other such inquiries. I release the company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.

I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded; my employment with the company may be terminated.
APPLICANT'S SIGNATURE*

Clear
M.M.P.&W Volunteer Fire & Ambulance Company Disclosure Policy on Criminal Activity

PLEASE READ AND CONFIRM THE BELOW CONDITIONS.
If you are currently engaged or have been engaged within the past five years, of the following criminal activity(ies), you may be denied membership/employment as it may threaten the health or safety of the members of this fire department:
- A record of conviction for any crime of violence (as that phrase is interpreted under the provisions of the PA Crimes Codes which is graded as a second degree misdemeanor or higher within 10 years of the date of application.) Crimes of violence shall include offenses involving acts or activities with
  minors where no actual force or threat of force was involved but where the minor was deemed as a matter of law incapable of consent to the activity. An example of the later activity is statutory rape. If you have engaged in such conduct but it did not result in a conviction, the company has the right to deny you membership/employment.
- A record of harassment (as defined in the aforesaid code or in a course of conduct which is a private or public nuisance under civil law) If this conduct was directed at or affected others living within the same household or others living in immediate vicinity to such individuals within a five year period. These provisions shall include but not be limited to unruly, loud, and profane activity arising from the use of alcohol or non-prescription drugs. No applicant shall have engaged in conduct directed toward an elderly person or an individual suffering from a disability including conduct constituting unfair business practices, fraud, deceit and similar offenses of conduct within ten years of the date of application regardless of whether or not such conduct resulted in a conviction.
- A conviction or engagement in a felony act (any conduct deemed a felony under the provisions of the PA Crimes Codes or the PA penal statute within the 5 year period prior to the application) If the conduct is a crime of violence, crime of violence shall include offenses involving acts or activities with minors where no actual force or threat of force was involved but where the minor was deemed as a matter of law incapable of consent to the activity.
- A conviction or engagement involving arson
Should past conduct prescribed by the above criteria have occurred in another jurisdiction, the conduct involved shall be evaluated on the basis of PA law for similar activities, actions, or convictions; provided; however, that it shall be presumed that a conviction for either a felony offense or a misdemeanor in another jurisdiction will be a disqualifying factor unless an applicant can establish by clear and convincing evidence that the offense is not one that would otherwise disqualify the applicant under these guidelines under Pennsylvania law.
I, First Name Last Name consent that I HAVE NOT been involved in criminal activity(ies) listed above.
I, First Name Last Name consent that I HAVE been involved in criminal activity(ies) listed above.
If you consented to being involved in the above criminal activity(ies), please provide additional information below:
The M.M.P.&W Volunteer Fire & Ambulance Company reserves the right to deny membership/employment to any individual that we feel may threaten the safety and welfare of our members.
Should be Empty:

Online Employment Application

PERSONAL INFORMATION

POSITION INFORMATION

CERTIFICATION INFORMATION

WORK REQUIREMENTS & GENERAL INFORMATION

EMPLOYMENT HISTORY

PAST EMPLOYMENT

EDUCATION AND TRAINING

REFERENCES

ACKNOWLEDGEMENT

M.M.P.&W Volunteer Fire & Ambulance Company Disclosure Policy on Criminal Activity