NORTHWEST CONSOLIDATED FIRE DISTRICT
EMPLOYMENT APPLICATION
	9745 Killcreek					913-583-3886
	DeSoto, KS   66018					Fax 913-583-1363
Name________________________________________					Maiden Name________________________
Address _____________________________________						Phone_____________________
City, State, Zip________________________________						S.S.N._____-________-_______
Date of Birth (DD/MM/YYYY)_____________________					Email Address _______________________
Date of Application____________________						Date Available_______________
Position Applying for_____________________________________						Salary	Volunteer
						(Circle One)
EDUCATION AND PROFESSIONAL TRAINING
Level of	Name of School				Type of		Field of		Year of
Education	or University			State	Diploma/Degree		Study		Graduation
High School
Jr.College
College
Trade/Tech.
Graduate
Describe any special qualifications, certificates, licenses, or skills that you possess pertinent to this agency.
Utilize additional sheet if more space is required.  Attach copies of all certificates.
EMPLOYMENT EXPERIENCE
Begin with current or most recent employer.  Include military and volunteer activities.  Exclude organizational names which indicate
race, color, religion, sex, sexual orientation, or national origin.
Employer__________________________________________________________________________________
City, State, & Zip Code_______________________________________________________________________
Telephone # ________-________-_________________					Supervisor's Name______________________________
Title________________________________				Reason for Leaving_______________________________________
Dates of Employment:		From___________		To_______________		Salary or Hourly Rate $____________/____
Employer #2______________________________________________________________________________
City, State, & Zip Code_______________________________________________________________________
Telephone # ________-________-_________________					Supervisor's Name______________________________
Title________________________________				Reason for Leaving_______________________________________
Dates of Employment:		From___________		To_______________		Salary or Hourly Rate $____________/____
Employer #3______________________________________________________________________________
City, State, & Zip Code_______________________________________________________________________
Telephone # ________-________-_________________					Supervisor's Name______________________________
Title________________________________				Reason for Leaving_______________________________________
Dates of Employment:		From___________		To_______________		Salary or Hourly Rate $____________/____
Personal/Professional References
								Telephone #
Name				City/State		Years Acquainted		(include area code)
Have you ever been:								Yes	No
Convicted of a violation of law other than minor traffic violations?
(This includes, but is not limited to misdemeanors, felonies, DWI, even if no time was served.)
Discharged or requested to resign from a former position?
Late reporting to work, for any employer, past or present?
Do you have any physical or mental conditions that would limit your performance?
Do you have a valid driver's license?				Issuing State_______		Exp. Date________
List all motor vehicle accidents in which you were involved during the three (3) years preceding the date of
this application.  Attach additional sheet if required.
Date of Incident		Nature of Incident				List fatalities or Personal Injuries
List all violations of motor vehicle laws or ordinances (excluding parking violations) that you were convicted
of or forfeited bond or collateral during the three (3) years preceding the date of this application.
Date of Violation		Nature of Violation(s)				Judicial Outcome of Violation(s)
List in detail any denials, revocations, or suspensions of any license, permit, or privilege you have had to
operate a motor vehicle.  Attach additional sheet if required.
My signature below authorizes Northwest Consolidated Fire District to conduct a background investigation and authorizes release of information in connection with my application
for employment.  This investigation may include such information as criminal or civil convictions, driving records, previous employers, educational institutions, personal references,
professional references, and information from other appropriate sources.  I waive my right of access to any such information, and without limitation hereby release Northwest
Consoldiated Fire District and the reference source from any liability in connection with its release or use.  This release includes the sources cited above and specific examples
as follows:  the local law enforcement agency,  information from the Central Criminal Records Exchange of either data on all criminal convictions or information from the
Central Criminal Records Exchange of either data on all criminal convictions or information from the Central Criminal Records Exchange of either data on all criminal convictions
or certification that no data on criminal convictions are maintained, information from the State and any Locality to which they may refer for release of information pertaining to
any findings. Furthermore, I certify that I have made true, correct, and complete answers and statements on this application in the knowledge that they may be relied upon in
considering my application, and I understand that any omission or falsification of any part of this application or any supplement to it will be sufficient grounds for failure to
employ or for my discharge should I become employed with Northwest Consolidated Fire District.
Date:  _______________________					Signature:  ___________________________________
Northwest Consolidated Fire District is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, political affiliations, sex,
religion, age, or disability in the admission or access to, participation, and employment in its programs, services, or activities.  Reasonable accomodation(s) will
be given upon request.