INDICATE POSITION

APPLYING FOR

Resident Firefighter ¨

Volunteer Firefighter ¨

Career Position ¨

Other:_____________________________________

CORDELIA FIRE PROTECTION DISTRICT

EMPLOYMENT APPLICATION

REMIT TO

Cordelia Fire Protection District

2155 Cordelia Rd.

Fairfield, Ca 94534

Telephone: 707-864-0468

Fax 707-864-8607

Office Hours M-F 9-12 & 1-5

IMPORTANT: As part of the recruitment process, you are required to complete this application. Complete all unshaded sections. An incomplete application will delay action and may disqualify you. Check carefully to be sure you meet the education and experience as stated on the announcement. note: Each applicant selected for employment will be fingerprinted/livescan and may be required to pass an administered health examination prior to being appointed. APPLICATIONS WITH OMITTED INFORMATION CANNOT BE CONSIDERED OR ASSUMED.

PRINt legibly IN INK OR TYPE

First Name Middle Last Name

Other Names under which you have worked

Street Address

City

State

Zip Code

Home Phone & Area Code

Email address (mandatory for dept mail)

Cell/Pager/Other Phone & Area Code

Social Security Number (Optional)

Are you 18 years of age?

Height

Weight

Sex

Male ¨ Female ¨

EDUCATION: You need only include education you believe relates to the position for which you are applying, as indicated in the Experience/Education portion of the job announcement. Be complete. Your application will be evaluated based on this information

Circle Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Do you speak/read and/or write a foreign language?

Name of High School/ City/State:

Did you graduate?

¨ Yes ¨ No

If not, do you have a G.E.D.?

¨ Yes ¨ No

Colleges Attended (Name & Location)

Dates attended (mm/yy)

From: To:

Full time or Part time

Credits Earned

(Sem or Qtr units)

Major

Degree (s)

Earned/Date

(mm/yy)

Professional Licenses or Certificates

Date Issued

(mm/yy)

Number

Expiration Date (mm/yy)

Attach Copies

Pertinent Training/Volunteer/Continuing Education Courses

Name of Learning Institution

Location

City/State

Length of course (Hrs/days/wks)

Number of CEU’s Earned?

Do you possess a valid California driver’s license?

¨ Yes ¨ No

License Number (and State if not CA)

Class (C/A/B/M)

Expiration Date (mm/dd/yy)

Has your Driver’s license ever been suspended or revoked?

¨ Yes ¨ No

Have you ever been fired or asked to resign from any position? ¨ Yes ¨ No If “Yes”, please attach a separate sheet with detailed information.

Have you ever been convicted of a misdemeanor or felony? ¨ Yes ¨ No (A conviction may not necessarily disqualify you for employment).

Date of Offense (mm/yy)

City & State

Charges

Penalties

Remarks

EMPLOYMENT HISTORY: List all work experience emphasizing experience directly related to the position for which you are applying. List the number of hours per week you worked (if qualifying experience is part time or voluntary, also list hours). Include all periods of self-employment and U.S. Military service. List each promotion separately. You will be evaluated based on this information. Additional copies of this form are available if required (you may also make copies). This section must be completed. Although a resume is required to be filed DO NOT indicate, “see attached resume” for purposes of this section, as this will be considered an incomplete application and may disqualify you.

From (mm/yy)	Present or most recent Employer (Business or Agency Name)				Address		City		State
To (mm/yy)	Title of your position			Name & Title of Supervisor –Address if Different				Agency Phone & Area Code
Total Yrs/Mos Worked Yrs Mos		Type of Organization						# of Employees Supervised
Hours Worked Each Week			Your Duties (List Primary Duties First)





			Reason for Leaving			If we contact your present employer, will your present position be endangered? ¨ Yes ¨ No
From (mm/yy)	Employer (Business or Agency Name)				Address		City		State
To (mm/yy)	Title of your position			Name & Title of Supervisor –Address if Different				Agency Phone & Area Code
Total Yrs/Mos Worked Yrs Mos		Type of Organization						# of Employees Supervised
Hours Worked Each Week			Your Duties (List Primary Duties First)





			Reason for Leaving
From (mm/yy)	Employer (Business or Agency Name)				Address		City		State
To (mm/yy)	Title of your position			Name & Title of Supervisor –Address if Different				Agency Phone & Area Code
Total Yrs/Mos Worked Yrs Mos		Type of Organization						# of Employees Supervised
Hours Worked Each Week			Your Duties (List Primary Duties First)





			Reason for Leaving

SUPPLEMENTAL INFORMATION: Please indicate if you possess any of the following certifications, licenses, education, and experience. Please include a copy of your current Resume as well as copies of all certificates, licenses, and additional information you feel will apply to this position.

¨ State Firefighter I ¨ State Firefighter II

¨ State Volunteer Firefighter I ¨ State Fire Officer

¨ Academy Firefighter I ¨ Fire Explorer Experience (#of months/location________________)

¨ Firefighter’s Class B License ¨ Volunteer Fire Experience (#of months/location_______________)

¨ EMT-Basic (county__________________) ¨ Paid Fire Experience (#of months/location____________________)

¨ EMT-Paramedic (county______________) ¨ Mechanic Experience (# of months__________)

¨ College Fire Technology (#of units______) ¨ Construction Trade Experience (#of months___________)

¨ College General Education (# of units____) ¨ Associates Degree (major______________)

¨ Bachelors/Master’s Degree (major____________) ¨ Technical Degree (major_______________)

Circle Days Available For Shift Work (Resident FF= 4- 24hr shifts per month, Volunteer FF= 2- 12hr shifts per month)

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Rotating Days

List any other State Certified Courses: ________________________________________ ________________________________________

________________________________________ ________________________________________ ________________________________________

EMERGENCY CONTACT INFORMATION: Please indicate contact person in case of emergency

Name & Relationship Address Home Phone Other Phone

REFERENCE CONTACTS: List four persons willing to provide professional and/or character references for you. Do not include relatives or previous employers. These people may be contacted during any part of the employment process.

Name Address, City, Zip code Occupation Length of Acquaintance

In the event that you are hired, you will be required to offer proof that you are a lawfully admitted alien or U.S. citizen. I understand that any omission or misrepresentation of material fact in this application may result in refusal of, or separation from, employment. I hereby authorize the Cordelia Fire Protection District to make any investigation of my background deemed necessary. I authorize my former employers to give any information regarding my employment. I hereby release them and their company/agency from all damages whatsoever for issuing same.

PRIOR TO APPOINTMENT TO THE POSITION OF FIREFIGHTER, THE APPLICANT MUST FURNISH A CURRENT DRIVER’S LICENSE RECORD AND SUBMIT TO LIVESCAN FINGERPRINTING.

Signature of Applicant _____________________ Date _

OFFICIAL USE ONLY	DATE STAMP

CORDELIA FIRE PROTECTION DISTRICT

PRINt legibly IN INK OR TYPE

First Name Middle Last Name

Other Names under which you have worked

Street Address

City

State

Zip Code

Cell/Pager/Other Phone & Area Code

Attach Copies

Signature of Applicant _____________________________________ Date _________________

DATE STAMP

Signature of Applicant _____________________ Date _