ESD #12 Application Updated 3/24/2018

HARRIS COUNTY ESD 12 FIRE DEPARTMENT
APPLICATION FOR EMPLOYMENT
Please take your time and complete ALL fields marked with a (*).

All submitted attachments must be in PDF format.

Double check your entries before pressing submit, as errors will prevent submission.

See closing note at the bottom of this application.
Position
Date of Application*

MonthDayYear
Position or Positions applying for:*

FirefighterDriver/EngineerCompany Officer/CaptainOther
Personal Information
Full Name*

First NameMiddle NameLast NameSuffix
Birth Date*

MonthDayYear
Social Security Number*
Are you a U.S. Citizen or do you have the right to work in the U.S.?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Have you ever been convicted of a felony?*

YesNo
If yes, please explain.
Are you related to any HCESD #12 Employees or Commissioners?*

YesNo
If yes, please explain.
Have you received any traffic citations and/or had any traffic accidents in the past five years?*

YesNo
Please list any traffic citations and/or accidents you have been involved in during the past 5 years.
1.
Date
2.
Date
3.
Date
Education
Name of High School*
Address (City/State)*
Did you graduate?*

YesNo
Graduation Date*

MonthDayYear
Diploma or GED*
Name of College or Fire Training Facility*
Address (City/State)*
Did you graduate?*

YesNo
Graduation (or expected) Date*

MonthDayYear
Degree or Certificate Received*
Name of College
Address (City/State)
Did you graduate?

YesNo
Graduation (or expected) Date

MonthDayYear
Degree Received
Work Experience
Please detail your work history for the last 10 years. Begin with your current or most recent employer. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation "See Resume." PLEASE NOTE: Harris County ESD No. 12 reserves the right to contact all current and former employers for reference information.
[Entry 1]
Organization Name*
Address*
Phone Number

Area CodePhone Number
Title*
Ending Salary*
Shift*

Full- TimePart- Time
Date Employed From*

MonthDayYear
Date Employed To*

MonthDayYear
Primary Duties*
Supervisor's Name, Title, and Contact Number*
Reason For Leaving*
Contact This Reference*
[Entry 2]
Organization Name
Address
Date Employed From

MonthDayYear
Date Employed To

MonthDayYear
Title
Ending Salary
Shift

Full- TimePart- Time
Primary Duties
Supervisor's Name, Title, and Contact Number
Reason For Leaving
Contact This Reference
[Entry 3]
Organization Name
Address
Date Employed From

MonthDayYear
Date Employed To

MonthDayYear
Title
Ending Salary
Shift

Full- TimePart- Time
Primary Duties
Supervisor's Name, Title, and Contact Number
Reason For Leaving
Contact This Reference
Emergency Contacts
Full Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Additional Items Requested
Please scan and provide digital copies of the following documents (if applicable to the position to which you are applying.) Only PDF format digital documents accepted.
Resumé*

Upload a File

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High School Diploma or Equivalent (Required for all applicants)*

Upload a File

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TCFP Firefighter Certification (Required for all applicants) *

Upload a File

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TCFP DOP Certification

Upload a File

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TCFP Fire Instructor I or Higher Certification (Required for Company Officer applicants)

Upload a File

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TCFP Fire Officer I or Higher Certification (Required for Company Officer applicants)

Upload a File

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Federal Highway Traffic Incident Management Certification (Required for all applicants) *

Upload a File

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Courage To Be Safe Certification (Required for all applicants) *

Upload a File

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NIMS 100,200,700, and 800 Certification (Required for all applicants)*

Upload a File

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Texas Department of State Health Services EMT Certification(Required for all applicants) *

Upload a File

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Valid Texas Driver's License - Copy Front and Back (Required for all applicants)*

Upload a File

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Legal Understanding
PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Harris County Emergency Service District No. 12 to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and driving background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Harris County ESD No. 12 serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States.
Signature*

Clear
Full Name*

First NameLast Name
Authorization
AUTHORIZATION FOR BACKGROUND CHECK

(Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.)

I hereby authorize Harris County Emergency Service District No. 12 to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Harris County Emergency Service District No. 12 will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.
Signature*

Clear
Full Name*

First NameLast Name
Submission
Note to applicant:

Be patient as the web-app is designed to "LOCK-UP" when you press SUBMIT to analyze the form for errors. This is to ensure the applicant does not make unwanted changes during analysis. Please DO NOT refresh or close the page!! Once the web-app has completed its analysis you will be able to scroll back through the application to complete the "red highlighted" error fields. Complete the errors then return to the bottom of the page. Press SUBMIT again and be patient while your application is analyzed again, or is submitted. Once completed, a "Thank You" screen will appear.
Submission Terms*

I Agree
Harris County Emergency Services District 12 is an equal opportunity employer, and hires without regard to race, color, gender, religion, national origin, ancestry, citizenship, disability, age, sexual orientation, or any other characteristic protected by law.
Should be Empty:

HARRIS COUNTY ESD 12 FIRE DEPARTMENT

APPLICATION FOR EMPLOYMENT

Position

Personal Information

Education

Work Experience

Emergency Contacts

Additional Items Requested

Legal Understanding

Authorization

Submission