Part Time Job Application

PART-TIME APPLICATION
Position Applying For:*

Part Time Paramedic/ FirefighterPart Time ParamedicCivilian Position
Available Start Date:

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:*

Area CodePhone Number
Cell Phone:*

Area CodePhone Number
Email Address*
Driver's License State:*
Driver's License No.:*
Expiration Date:*
Social Security No.*
Birth Date*

MonthDayYear
US Citizen?

YesNo
How did you learn about this job?

Military
Are you now or have you ever been in the military service?

YesNo
Branch of Service:
Conviction History
Have you ever been convicted of a crime other than minor traffic violations?

YesNo
List all traffic convictions and accidents you have had in the last (4) years:
Approximate Date:

MonthDayYear
Date
Violation
Disposition:

Employment History
Upload Resume Here

Browse Files

Cancelof
Present Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

YesNo
Previous Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

YesNo
Previous Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Job Description
Dates of Employment (Month & Year)
May we contact your employer?

YesNo

References
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area CodePhone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area CodePhone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Relationship
Phone Number

Area CodePhone Number
Please review the enclosed job description for the position for which you are applying and state whether you can perform the essential job functions listed therein with or without reasonable accommodation.
YesNo
If accommodation is needed, please explain:
Emergency Contacts
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Acknowledgement
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS AND STATEMENTS, AND I CERTIFY THAT THERE ARE NO MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS IN THIS APPLICATION, AND THAT ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS ON THIS APPLICATION OR AT ANY TIME DURING THE HIRING PROCESS MAY RESULT IN MY APPLICATION NO LONGER BEING CONSIDERED OR IN TERMINATION OF MY EMPLOYMENT WITH THE BENSENVILLE FIRE PROTECTION DISTRICT.
DATED:

MonthDayYear
Date
Signature
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, or physical or mental handicap. All information provided in this application will be treated confidentially and will be used to help assure the best use of your abilities if you are employed with us.

If reasonable accommodation is needed for the testing process because of a disability, please notify the Board of Fire Commissioners in writing as to the specific accommodation needed.
FOR OFFICE USE ONLY
INTERVIEW DATE

MonthDayYear
Date
HIRE DATE

MonthDayYear
Date
TESTED IN LOYOLA SYSTEM

YESNO
Should be Empty:

Education

Military

Conviction History

Employment History

References

Emergency Contacts

Acknowledgement