Thank you for your interest in serving as a firefighter or emergency medical services personnel with the Washington Fire Department, Inc.

Please answer each question completely. Every statement made is subject to verification.

The Washington Fire Department seeks qualified individuals who are interested in serving the community. The Department does not discriminate on the basis of sex, race, religion, color, age, physical impairment, or national origin.

After your application has been submitted and an initial evaluation has been completed, applicants approved for membership will be asked to meet with the leadership of the Washington Fire Department, Inc.

If you are preliminarily selected for the position, you will be asked to complete a medical questionnaire and undergo medical screening at the expense of the Fire Department. In addition, a background check will be conducted to verify your suitability for the position for which you are applying.

Again, thank you for your interest in the Washington Fire Department. We look forward to meeting with you to further discuss the Fire Department and the contributions you can make to the citizens of the community we serve.

Education History

Please list all schools attended, the dates of attendance, and any certificate, diploma or degree awarded.

Work History

For your current and past employments, fill in the below information.

References

List two persons whom we may contact who are not related to you, and who have definite knowledge of your qualifications and fitness to serve as a member of the Washington Fire Department.

ACKNOWLEDGMENT OF RISKS AND CONDITIONS
EMS PROVIDERS
WASHINGTON FIRE DEPARTMENT, INC.

An individual applying for a position with the Washington Fire Department, Inc. as an emergency medical technician must understand and acknowledge certain conditions which will exist during the time of this association with the department. Because of the nature of the activities in which the department is engaged, an individual associated with the department will be exposed to certain hazards.

Serving as an EMT with the department will involve physical exertion, emotional, and psychological stress, and exposure to hazardous substances and conditions.

Before beginning association with the Washington Fire Department, Inc., an individual must therefore read and sign the following form.

I acknowledge the following:

1. Providing emergency medical services can be a physically and mentally challenging and stressful activity, requiring significant physical exertion, an ability to react quickly in emergency situations, exposure to high temperature and humidity levels, toxic atmospheres, working at great heights and in confined spaces, and exposure to disease, among other conditions. This can result in the potential for sickness, accident and injury. This work necessarily results in increased pulse, respiration, and blood pressure, and can result in elevated body temperatures.

2. Because of the physical challenges involved in these activities, persons with known physical limitations which may affect health and safety under the conditions described above, including but not limited to heart and lung disease and hypertension, are advised to check with a physician before participating in fire department activities.

3. During my time of association with the Washington Fire Department, Inc., I will be required to remain in a physical condition which will allow me to respond to the challenges of my position as an EMT with the department, and to regularly participate in the training and education programs offered to members, so that I will be better aware of dangerous conditions, and better able to respond to them.

4. Appropriate protective clothing is to be worn at all times when conditions warrant.

5. No individual shall be under the influence of alcohol, or of any other substance, prescription or otherwise, which may affect mental or physical reactions, at the time of performing any activities as a member of the Washington Fire Department, Inc.

6. The Washington Fire Department, Inc. has adopted certain rules and regulations relating to Firefighter/EMT health and safety. These must be followed at all times.

7. I will notify my supervisors of any change in my EMT status promptly upon learning of such a change, and will not provide any care beyond my level of training and license.

ACKNOWLEDGMENT OF RISKS AND CONDITIONS
Firefighters and Rescue Personnel
WASHINGTON FIRE DEPARTMENT, INC.

An individual applying for a position as a member with the Washington Fire Department, Inc. must understand and acknowledge certain conditions which will exist during the time of this association with the department. Because of the nature of the activities in which the department is engaged, an individual associated with the department will be exposed to certain hazards.

Service on the department will involve physical exertion, physical, emotional, and psychological stress, and exposure to hazardous substances and conditions.

Before beginning association with the Washington Fire Department, Inc., an individual must therefore read and sign the following form.

I acknowledge the following:

1. Fire-fighting and rescue activities can be physically and mentally challenging and stressful activities, requiring significant physical exertion, an ability to react quickly in emergency situations, exposure to high temperature and humidity levels, toxic atmospheres, working at great heights and in confined spaces, among other conditions. This can result in the potential for accident and injury. This work necessarily results in elevated body temperatures, and in increased pulse, respiration, and blood pressure.

2. Because of the physical challenges involved in fire-fighting and rescue activities, persons with known physical limitations which may affect health and safety under the conditions described above, including but not limited to heart and lung disease and hypertension, are advised to check with a physician before participating in fire department activities.

3. During my time of association with the fire department, I will be required to remain in a physical condition which will allow me to respond to the challenges of my position with the department, and to regularly participate in the training and education programs offered to members, so that I will be better aware of dangerous conditions, and better able to respond to them.

4. Protective clothing is to be worn at all times when conditions warrant. Individuals with facial hair, jewelry, or any other condition which may interfere with the proper seal of a face piece on self-contained breathing apparatus should avoid any situations where the atmosphere is toxic, or may become toxic.

5. No individual shall be under the influence of alcohol, or of any other substance, prescription or otherwise, which may affect mental or physical reactions, at the time of performing any activities as a member of the Washington Fire Department, Inc.

6. The Washington Fire Department, Inc. has adopted certain rules and regulations relating to firefighter health and safety. These must be followed at all times.

Please read the following statement carefully before signing.

I certify that the statements made above are true and correct. I understand that if any of the statements made are false or misleading, this may be cause for discipline, and any position that I might be offered may be withdrawn.

By signing this application, I authorize the Washington Fire Department, Inc. and its agents to investigate my background and qualifications, contact persons familiar with me, and verify any statements made in this application. This authorization includes the right to receive and review a copy of my driving abstract. I release the Washington Fire Department, Inc., its officers and agents, and any person who might be contacted regarding my qualifications from any claims or liability that might otherwise result from any investigation performed or information provided pursuant to my application.

If accepted, I agree to abide by the rules and regulations of the Washington Fire Department, Inc.

I understand that, if accepted, I will be required to undergo a physical examination and provide certain medical background information regarding my physical ability to perform the duties of a firefighter, rescue squad member, or EMT for the Washington Fire Department, Inc.

I understand that service with the Fire Department in the position for which I am applying involves certain risks. I understand that I will be required to remain physically fit and regularly participate in the training and education programs conducted by the Fire Department.

I understand that I will be required at all times to possess a valid Illinois driver's license. I am attaching a copy of my current, valid Illinois driver's license to this application.

I understand that a person applying for a position as an Emergency Medical Technician must become certified as an Emergency Medical Technician-Ambulance within one year of the date of membership, unless this period is extended by the Fire Department for good cause shown.

I understand that, as a condition of employment, I will be fingerprinted by the Washington Police Department, and a set of fingerprints will be furnished to the Illinois State Police and FBI.

Authorization, Release, and Equal Employment Opportunity Statement

I hereby authorize the Washington Fire Department Inc. and its agents, employees or representatives to obtain and use all information relating to my previous and current employment, education, military record, credit record, criminal conviction history, personal characteristics and all other information which may bear favorably or unfavorably upon my application for employment made to the Washington Fire Department Inc.

I also consent to the release to the Washington Fire Department Inc. of any and all medical records prepared during the physical examination I am required to under go for employment with the Washington Fire Department Inc.

I further release from liability any person or persons providing or receiving any such information in connection with this pre-employment investigation.

I also agree to indemnify and hold harmless the Washington Fire Department Inc., the Board of Directors of the Washington Fire Department Inc, employees and agents against any claim or loss whatsoever, including but not limited to attorney's fees and any cost of defense which arises directly or indirectly out of any injury which I might sustain in the application process.

I also covenant that for the consideration of my application, I agree not to sue the Washington Fire Department Inc, the individual board members, employees and agents for any injury, loss or damage as a result of such process including but not limited to personal injury, wrongful death, court costs, attorneys' fees and interest, in any manner caused directly or indirectly, including the negligent acts or omissions of the Washington Fire Dept Inc, its board members as well as its employees and agents.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

This organization is committed to the policy of equal employment opportunity in recruitment, hiring, career advancement, and all other personnel practices. Your job related experience and other qualifications will be considered without discrimination on the grounds of race, color, religion, sex, national origin, age, marital status, or physical or mental disability.

All information provided in this application will be treated confidentially, and will be used only to help assure the best use of your abilities if you are employed with us.