BRFD Application

Please complete this application accurately and thoroughly.

All statements in your application are subject to verification. False statement(s) can potentially bar or remove you from employment. Use the term ‘NA’ (not applicable) if the question does not apply.

Applicants between 16-18 years of age who are still in high school will be considered a Cadet.
Part-Time Paramedic or EMTVolunteer
Application Date*

MonthDayYear
Name (Last, First Middle)*
List any other names or aliases you have been known by (including maiden name if applicable)
Home Address
Cell Phone*
Format: (000) 000-0000.
Email*
Date of Birth*

MonthDayYear
MaleFemale
YesNo
Native BornNaturalized
SingleMarriedSeparatedDivorcedWidowed
YesNo
Drivers License Number*
License Classification*
FFII or BOFHAZMATFSVOEMTParamedicCPR/First Aid
EDUCATION
High School Attended (including city & state)*
Date(s) attended:*
YesNo
College or University Attended (including city & state):
Date(s) attended:
YesNo
Other Educational Institution (including city & state):
Date(s) attended:
YesNo
YesNo
If yes, explain:
CRIMINAL HISTORY
YesNo
Date(s)

MonthDayYear
By whom (agency)
Charges
Disposition of case
If yes, explain
YesNo
If yes, explain
EMPLOYMENT
List all jobs you have held for the last three (3) years, including periods of unemployment, starting with your most recent job.
Employer
Address
Type of business
Supervisor
Start Date
End Date
Title or position
Job description
Employer
Address
Type of business
Supervisor
Start Date
End Date
Title or position
Job description
Employer
Address
Type of business
Supervisor
Start Date
End Date
Title or position
Job description
REFERENCES
List three (3) persons below, not related to you and not former employers, whom you have known for more than five (5) years. All persons listed will be asked to appraise your character, ability, experience, personality, and other qualities.
Reference 1*
Phone*
Format: (000) 000-0000.
Years known*
Occupation/profession*
Business Address*
Reference 2*
Phone*
Format: (000) 000-0000.
Years known*
Occupation/profession*
Business Address*
Reference 3*
Phone*
Format: (000) 000-0000.
Years known*
Occupation/profession*
Business Address*
I certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers, and that the entries made by me above are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I further agree and consent in advance to being summarily discharged without cause or hearing if any of the above information contains any misrepresentations or falsifications or if any material information has been omitted.

I authorize and empower the Big Rock Fire Protection District to obtain, prepare, use and furnish information concerning my current and former employment, education, credit, general reputation, criminal record (if any), health, and personal characteristics through records, correspondence, or personal interviews with neighbors, friends, associates, or others with whom I am acquainted, or who may have knowledge concerning any of the above items. I swear or affirm that the above information is true and correct to the best of my knowledge.
Applicant Signature*
Date*

MonthDayYear
Should be Empty:

EDUCATION

CRIMINAL HISTORY

EMPLOYMENT

REFERENCES