Firefighter Application

*Name

*DateDate of Application

*Address

*Email

*Phone Number

*Position

*If offered employment, when will you be available to begin?

*Have you been given a job description or had the requirements of the job explained to you?

Yes No

*Do you understand the job requirements?

Yes No

*Can you perform the essential functions of this job with or without reasonable accommodation?

Yes No

*To qualify for employment, applicants must be at least 18 years of age unless otherwise specified in the job announcement. If offered employment, can you furnish proof of age?

Yes No

*After an offer of employment, can you submit verification of your legal right to work in the United States?

Yes No

List other names, if any, you have used.

EDUCATION RECORD

For positions which require a high school graduation or GED or a college degree, a copy of the high school diploma/GED certificate or college diploma/transcripts may be required.

*Did you graduate from high school or receive a GED certificate?

Yes No

*Name of Business/Technical/Vocational School

*Business/Technical/Vocational School Location

*Business/Technical/Vocational School major or field of study

*Hours Earned

*Did you receive a Diploma, Degree, or Certificate

Yes No

*Name of College/University

*College/University Location

*College/University Diploma, Degree or Certification

Yes No

*College/University major or field of study

Name of Graduate School

Graduate School Location

Graduate School Diploma, Degree or Certification

Graduate School major or field of study

LICENSES

(Optional, unless required for the position for which you are now applying.)

*List current licenses, certifications, or registrations required for the position for which you are applying. Indicate types, state license numbers, and expiration dates.

*Do you possess a valid driver’s license?

Yes No

*If so, State / Expires

*Class & Restrictions (if any)

*For positions that require typing: I certify that I can type at a speed of_____ MPH

*In addition to English, list any other language abilities you possess.

*List any special skills you possess and/or equipment or office machines you can operate.

OTHER INFORMATION

*Have you ever been disciplined in your employment related to workplace violence?

Yes No

*If yes, please explain.

*Do you presently use illegal drugs?

Yes No

*Have you ever been employed by North Lyon County Fire Protection District?

Yes No

*If yes, please provide the following information: Related person’s name, department & relationshipRelated person’s name, department & relationship

*Are you related to anyone who is currently employed by North Lyon County Fire Protection District?

Yes No

*Have you ever been convicted of, pled guilty or nolo contendere to, or been granted deferred adjudication for a felony, misdemeanor (excluding juvenile adjudication), or any lesser crime other than a minor traffic infraction?.....

Yes No

*Do you have any pending court charges that have not been adjudicated?

Yes No

*If you have answered yes to either question, list all such offenses and provide date, name of court, and disposition (if any). You may omit minor traffic violations for which you paid a fine of $50 or less. Omission of information may be considered cause for disqualification from the employment pre-screening process or result in termination of employment.

EMPLOYMENT HISTORY

Provide information regarding all paid employment (include military employment if duties/assignments relate to the job you are applying for). Volunteer work which may be related to the position for which you are applying should also be provided. Describe your most recent position first; then list other positions in order held. Do NOT use references such as “See Resume” in place of completing this section.

*May we contact all employers listed? (Attach a list of any exceptions with an explanation.)

Yes No

Attachment

*Present Employer

*Present Position

*Address, City, State, Zip Code

*Full-Time or Part-Time?

Full-Time (30+ hrs/wk) Part-Time (<30 hrs/wk)

*From (Mo/Yr)

*To (Mo/Yr)

*Supervisor’s Name/Title

*Telephone

*Related Duties:

*Reason for Leaving:

*Employer #2

*Position

*Address, City, State, Zip Code

*Full-Time or Part Time?

Full-Time (30+ hrs/wk) Part-Time (<30 hrs/wk)

*From (Mo/Yr)

*To (Mo/Yr)

*Supervisor’s Name/Title

*Telephone

Related Duties:

*Reason for Leaving:

*Employer #3

*Position

*Address, City, State, Zip Code

*Full-time or part-time?

Full-Time (30+ hrs/wk) Part-Time (<30 hrs/wk)

*From (Mo/Yr)

*To (Mo/Yr)

*Supervisor’s Name/Title

*Telephone

*Related Duties:

*Reason for Leaving:

Employer #4

Position

Address, City, State, Zip Code

Full-Time or Part-Time?

Full-Time (30+ hrs/wk) Part-Time (<30 hrs/wk)

From (Mo/Yr)

To (Mo/Yr)

Supervisor’s Name/Title

Telephone

Related Duties:

Reason for Leaving:

*Please state below any other information that would be helpful in determining your qualifications for this position. You may include significant accomplishments, previous career highlights, or any other relevant information that is not requested in this employment application.

ACKNOWLEDGMENTS

Please READ ALL of the following statements and INITIAL EACH of the lines to indicate you have read and understand each of the statements. If you have any questions, contact North Lyon County Fire Protection District Human Resources Department.

*All offers of employment and all information regarding compensation and other terms and conditions of employment will be made in writing. Verbal statements may not be relied upon.

*This application is the property of North Lyon County Fire Protection District and will become part of my personnel file if I am hired.

*I authorize North Lyon County Fire Protection District to contact any employer or individual to obtain from them any relevant information regarding my previous employment, military service, criminal history, characteristics or traits necessary for job performance, or other relevant qualifications for employment and/or continued employment with North Lyon County Fire Protection District. In addition, I authorize North Lyon County Fire Protection District to conduct a background search which includes criminal history and military history. In addition, if the position for which I am applying requires driving a vehicle, I authorize North Lyon County Fire Protection District to conduct a Department of Motor Vehicles (DMV) search. If the position for which I am applying involves contact with minors or with any persons having diminished capacity to care for themselves, a search of government sex offender registries may be conducted. I further authorize North Lyon County Fire Protection District to contact any institution and/or licensing authority to verify my possession of education, licenses, and/or certificates which may qualify me for employment.

*In exchange for North Lyon County Fire Protection District consideration of my employment application, and/or any continued employment with North Lyon County Fire Protection District, I authorize anyone possessing information to furnish it to North Lyon County Fire Protection District upon request, and I release the organizations and all individuals providing the information or acquiring the information, including North Lyon County Fire Protection District from all claims, liability, and damages whatsoever claimed to be related to furnishing, obtaining, or using said information. This release applies to, but is not limited to, claims for defamation, libel, slander, infliction of emotional distress, and interference with current or prospective economic relations.

*I further understand this consent will apply during the entire course of my employment with North Lyon County Fire Protection District should I obtain such employment. I understand and agree this consent shall remain in affect indefinitely.

*I hereby certify that all statements made in this application are true. I understand that any false statement of material facts herein may cause forfeiture on my part of all rights to any employment with North Lyon County Fire Protection District. I understand that any misrepresentation, falsification, or material omission of information may result in my failure to receive an offer, or if I have been hired, in my dismissal from employment regardless of length of employment. I understand that neither this document nor any offer of employment from North Lyon County Fire Protection District constitutes an employment contract unless a specific contract document to that effect is executed. I agree to undergo any job-related drug screening and physical examination upon conditional offer of employment. I understand that North Lyon County Fire Protection District is not requesting genetic information from the drug screening or the physical examination and that the person administering the examination should not provide genetic information to North Lyon County Fire Protection District. I further understand and agree that this paragraph applies to any information supplied by me at a later date as part of this application.

*Per NRS 281.060 (2), I opt to exercise my rights by voluntarily attaching a copy of my DD214. NRS 281.060(2) states preference must be given, if qualifications of applicants are equal: a) first, to an honorably discharged military personnel of the United States who is a citizen of Nevada; and b) second, to other citizens of Nevada.

*Additionally, my signature below certifies that the information provided is true and correct to the best of my knowledge.By typing your name above you are acknowledging that this serves as your digital signature.

Fields with (*) are compulsory.

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