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NORTHWEST CONSOLIDATED FIRE DISTRICT |
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EMPLOYMENT APPLICATION |
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9745 Killcreek |
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913-583-3886 |
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DeSoto, KS 66018 |
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Fax 913-583-1363 |
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| Name________________________________________ |
Maiden Name________________________ |
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| Address _____________________________________ |
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Phone_____________________ |
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| City, State, Zip________________________________ |
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S.S.N._____-________-_______ |
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| Date of Birth (DD/MM/YYYY)_____________________ |
Email Address _______________________ |
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| Date of Application____________________ |
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Date Available_______________ |
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| Position Applying for_____________________________________ |
Salary |
Volunteer |
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(Circle One) |
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| EDUCATION AND PROFESSIONAL TRAINING |
| Level of |
Name of School |
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Type of |
Field of |
Year of |
| Education |
or University |
State |
Diploma/Degree |
Study |
Graduation |
| High School |
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| Jr.College |
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| College |
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| Trade/Tech. |
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| Graduate |
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| Describe any special qualifications, certificates, licenses, or skills that you possess pertinent to this agency. |
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| Utilize additional sheet if more space is required. Attach copies of all certificates. |
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| 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. |
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| Employer__________________________________________________________________________________ |
| City, State, & Zip Code_______________________________________________________________________ |
| Telephone # ________-________-_________________ |
Supervisor's Name______________________________ |
| Title________________________________ |
Reason for Leaving_______________________________________ |
| Dates of Employment: |
From___________ |
To_______________ |
Salary or Hourly Rate $____________/____ |
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| Employer #2______________________________________________________________________________ |
| City, State, & Zip Code_______________________________________________________________________ |
| Telephone # ________-________-_________________ |
Supervisor's Name______________________________ |
| Title________________________________ |
Reason for Leaving_______________________________________ |
| Dates of Employment: |
From___________ |
To_______________ |
Salary or Hourly Rate $____________/____ |
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| Employer #3______________________________________________________________________________ |
| City, State, & Zip Code_______________________________________________________________________ |
| Telephone # ________-________-_________________ |
Supervisor's Name______________________________ |
| Title________________________________ |
Reason for Leaving_______________________________________ |
| Dates of Employment: |
From___________ |
To_______________ |
Salary or Hourly Rate $____________/____ |
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| Personal/Professional References |
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Telephone # |
| Name |
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City/State |
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Years Acquainted |
(include area code) |
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| Have you ever been: |
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Yes |
No |
| Convicted of a violation of law other than minor traffic violations? |
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| (This includes, but is not limited to misdemeanors, felonies, DWI, even if no time was served.) |
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| Discharged or requested to resign from a former position? |
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| Late reporting to work, for any employer, past or present? |
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| Do you have any physical or mental conditions that would limit your performance? |
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| Do you have a valid driver's license? |
Issuing State_______ |
Exp. Date________ |
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| 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. |
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| Date of Incident |
Nature of Incident |
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List fatalities or Personal Injuries |
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| 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. |
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| Date of Violation |
Nature of Violation(s) |
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Judicial Outcome of Violation(s) |
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| 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. |
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| 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. |
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| Date: _______________________ |
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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 |
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| be given upon request. |
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