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2. I. Personal Information
4. Full Name (First, Middle, Last)*
6. Present Address (Please include City, State, Zip)*
8. Permanent Address (if different than above)
10. Telephone Number*
11. Email Address
13. Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination. Employment participates in the E-Verify program.
15. Position Applied For:*
17. 1. Is there any information we would need about your name or use of another name for us to be able to check your work record? Please specify:*
19. 2. Do you have any relatives who are presently (or have formerly been) employed by the City of Willow Springs?*
21. 3. How were you referred to us?*
23. 4. Have you ever been convicted of a felony?*

    1. Yes
    2. No
24. If yes, please explain:
26. II. Educational History

    School Name / Location / Years Completed / Degree / Diploma

28. Elem / Jr. High:
30. High School:
32. College:
34. Tech Training:
36. Other:
38. III. Employment Record

    Please include all employment for the last five years.

40. 1. Company Name (Current / Most Recent Employer)
41. Position Held
43. Address (Street, City, State, Zip)
44. Dates Employed:
46. Manager / Supervisor
47. Telephone
48. Wage / Salary
50. Reason for Leaving:
52. 2. Company Name
53. Position Held
55. Address (Street, City, State, Zip)
56. Dates Employed:
58. Manager / Supervisor
59. Telephone
60. Wage / Salary
62. Reason for Leaving:
64. 3. Company Name
65. Position Held
67. Address (Street, City, State, Zip)
68. Dates Employed:
70. Manager / Supervisor
71. Telephone
72. Wage / Salary
74. Reason for Leaving:
76. NOTE: List additional employers below, if necessary. We will contact all of the employers listed on this application unless you specifically exclude them below. Please list any employers you do not want us to contact and your reason for the exclusion:
78. Do you have any previous Fire or EMS experience, not already listed above? If yes, please list the name of the department, supervisor's name, telephone number, and dates of service.
80. Do you have Fire I and Fire II certification? If yes, please state where you obtained such certification and the date.
82. Do you have EMT certification? If yes, please state where you obtained such certification and the date.
84. Please provide copies of all certificates referenced above, if any.
86. IV. References

    Please do not include relatives or former employers.

88. 1. Name (First and Last)
89. Years Known
90. Telephone
92. Address (Street, City, State, Zip)
93. Occupation
95. 2. Name (First and Last)
96. Years Known
97. Telephone
99. Address (Street, City, State, Zip)
100. Occupation
102. 3. Name (First and Last)
103. Years Known
104. Telephone
106. Address (Street, City, State, Zip)
107. Occupation
109. V. Work Availability
111. If your application receives favorable consideration, when will you be available to begin work?*
113. Do you have a driver's license?*

     1. Yes
     2. No
114. Driver's License type:

     1. Operator
     2. Commercial (CDL)
     3. Chauffeur
115. Driver's License Number
116. State of Issue / Expiration
118. What is your means of transportation to/from work?*
120. Have you had any accidents in the past three years? If yes, please state how many.
121. Have you had any moving violations in the past three years? If yes, please state how many.
123. VI. Agreement

     It is our policy to check references as part of our hiring process. This may include contacting your former employers, as well as other business associates. We will ask a series of questions about your work experience, character, education, and personality.

     
     

     I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

     
     

     I understand that, in connection with the routine processing of your employment application, the Company may request a Driver's Motor Vehicle Record and a background check. Upon written request from me, the Company will provide me with a copy of these records.

     
     

     I further understand that my employment with the Company shall be probationary for a period of six months, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

     After reading this policy, please indicate your agreement by electronically signing in the space provided by typing my full name.

     
     

     I have read and fully understand the foregoing and voluntarily consent to allow the Company to check my references. Questions may be asked about my work experience, personality, personal habits, and education.

125. Applicant's Electronic Signature

     Please type First and Last Name.

126. Date
Leave This Blank:


128. 1. Receive an email copy of this form.
129. Email address

     This field is not part of the form submission.

130. Submit Submit and Print

* indicates a required field