Contact Information:

Today's date: *

First Name: *

Current Address: *

Day phone: *

Evening phone: *

Email Address: *

Employment Desired:

Employment Desired: Firefighter ApplicantVolunteer FirefighterExplorerSupport Group

Position applying for: *

Full time: YesNo
Part time: YesNo
Temporary: YesNo
If you choose "Yes" to Temporary, what period will you be available?: From: to

What days and hours are you available for work?:

Are you available to work on weekends?: * YesNo

Are there any hours you are unable to work?: * YesNo

If yes, what hours are you unable to work?:

If hired, on what date can you start work?:

Why are you applying for work here?:

Do you have any relatives or friends working here?: * YesNo
If yes, state name(s) and relationship(s):

Are you at least 18 years old?: * YesNo

If hired, would you have a reliable means of transportation to and from work?: * YesNo

Are you legally eligible to work in the United States?: * YesNo

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?: * YesNo
If no, describe the functions that cannot be performed:

Note: We comply with Federal, State and Local regulations and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire maybe subject to passing a medical examination, and skill and agility tests.)

Education, Training and Experience:

High School: Address:
# of years completed:
Did you graduate?: * YesNo
Degree/Diploma?: * YesNo

College/University: Address:
Did you graduate?: * YesNo
Degree/Diploma?: * YesNo

Vocational/Business/Other: Address:
Did you graduate?: * YesNo
Degree/Diploma?: * YesNo

Are you currently employed? * : YesNo
If yes, may we contact your current employer?: * YesNo

Do you have any other experience, training, qualifications, license, certification or skills that you feel make you especially suited for this position?: * YesNo
If yes, please explain:

Employment History:

Job #1:
-- Name:
-- Address:
-- City, state, zip:
-- Phone #:
-- Supervisor's Name:
-- Dates of Employment: to
-- May we contact this employer as a reference?: YesNo
-- Job title:
-- Job responsibilities:
-- Reason for leaving:

Job #2:
-- Name:
-- Address:
-- City, state, zip:
-- Phone #:
-- Supervisor's Name:
-- Dates of Employment: to
-- May we contact this employer as a reference?: YesNo
-- Job title:
-- Job responsibilities:
-- Reason for leaving:

Job #3:
-- Name:
-- Address:
-- City, state, zip:
-- Phone #:
-- Supervisor's Name:
-- Dates of Employment: to
-- May we contact this employer as a reference?: YesNo
-- Job title:
-- Job responsibilities:
-- Reason for leaving:

Do you object to MFPD making inquiry to any of your present or prior employers? * YesNo
If yes, which one(s)?:

References:

List below two persons not related to you who have knowledge of your work performance within the last three years:

-- First and last name:
-- Address:
-- City, state, zip:
-- Telephone #:
-- Occupation:
-- Number of years acquainted:

-- First and last name:
-- Address:
-- City, state, zip:
-- Telephone #:
-- Occupation:
-- Number of years acquainted:

Acknowledgment:

Please read carefully and sign below.
I hereby certify that I have not knowingly withheld any information that might adversely affect my eligibility for employment and that the answers given by me are true and accurate. I understand that any omission or misstatement on this application or on any document used to secure employment shall be grounds for rejection of this application or termination of employment if employed, regardless of the time elapsed before discovery.

I hereby authorize Mosquito Fire Protection District to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed, except those as noted, to disclose to Mosquito Fire Protection District any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Mosquito Fire Protection District and my former employers from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I further agree to be fingerprinted, to submit to a medical examination, which will include drug testing, and, upon employment, to furnish such proof of age as may be required.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Today's date: *

Your signature: *