1
APPLICATION FOR EMPLOYMENT
CITY OF ARKADELPHIA
FIRE DEPARTMENT
610 CADDO ST.
ARKADELPHIA, AR 71923
An Equal Opportunity Affirmative Action Employer
Position Applying for (Full Time or Part Time Fire)
_______
PAID PER-CALL
________
Name
_________________________________________
Are you 21 or older
_______
(Last) (First) (Middle)
Drivers License # & State:
____________________
Social Sec. #:
___________________
Mailing Address
___________________________________________________________
Telephone number where you may be reached
____________________________________
or a message may be left for you.
If you are hired, can you produce evidence of U.S. citizenship or legal work status within
three (3) days?
_________________
PREVIOUS EMPLOYMENT: List all employment (Including military service) for at least the past five (5)
years. Begin with your most recent employment and work back. You may attach additional sheets or a
resume to provide sufficient qualifying experience data.
From
______________________________
To
______________________________________
Job Title
_____________________________________
Annual Salary$
___________________
Firm Name
_________________________
Address
__________________________________
Name of Direct Supervisor
_______________________________
Phone
__________________
Reason for Leaving
____________________________________________________________
Description of Work
___________________________________________________________
From______________________________ To_______________________________________________________
Job Title _____________________________________ Annual Salary$ ___________________ _____________________
Firm Name_________________________ Address__________________________________________________________
Name of Direct Supervisor _______________________________ Phone _____________________________________
Reason for Leaving ____________________________________________________________________________________
Description of Work ___________________________________________________________________________________
PREVIOUS EMPLOYMENT: List all employment (Including military service) for at least the past five (5)
years. Begin with your most recent employment and work back. You may attach additional sheets or a
resume to provide sufficient qualifying experience data.
From
______________________________
To
______________________________________
Job Title
_____________________________________
Annual Salary$
___________________
Firm Name
_________________________
Address
__________________________________
Name of Direct Supervisor
_______________________________
Phone
__________________
Reason for Leaving
____________________________________________________________
Description of Work
___________________________________________________________
From______________________________ To_______________________________________________________
Job Title _____________________________________ Annual Salary$ ___________________ _____________________
Firm Name_________________________ Address__________________________________________________________
Name of Direct Supervisor _______________________________ Phone _____________________________________
Reason for Leaving ____________________________________________________________________________________
Description of Work ___________________________________________________________________________________
2
College, University, Trade,
Business, Correspondence
Dates of
Attendance
Major Areas of Study Semester
Hours
Degree’s
Granted
Date left or
Graduated
Can you perform the duties of the job for which you are applying? Yes No
If No, please explain:
___________________________________________________________
Specify equipment or office machines you operate:
______________________________________
____________________________________________________________________________
____________________________________________________________________________
From
______________________________
To
______________________________________
Job Title
_____________________________________
Annual Salary$
___________________
Firm Name
_________________________
Address
__________________________________
Name of Direct Supervisor
_______________________________
Phone
__________________
Reason for Leaving
____________________________________________________________
Description of Work
___________________________________________________________
From______________________________ To_______________________________________________________
Job Title _____________________________________ Annual Salary$ ___________________ _____________________
Firm Name_________________________ Address__________________________________________________________
Name of Direct Supervisor _______________________________ Phone _____________________________________
Reason for Leaving ____________________________________________________________________________________
Description
of Work ___________________________________________________________________________________
EDUCATION:
Did you graduate from High School? Yes No
Name and address of High School__________________________________________________________________
Last grade completed and date of completion or graduation _______________________________________
3
Are you related to any member of the Arkadelphia City Council or any person now in the employment of
the City of Arkadelphia: Yes No.
If yes, give person’s name, where employed, and relationship to you:
____________________________________________________________________________
Person to be notified in case of emergency:
____________________________________________________________________________
(Name) (Address) (Telephone)
Give the names, addresses, and telephone numbers of three (3) persons, other than relatives, who have
knowledge of your character, experience or ability:
Name Address Telephone Occupation
List any arrests for which you were convicted or paid fines:
Date
Location
Charge
Please indicate any additional experience and/or training you have had, which, in your opinion, would
qualify you for the position you seek:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4
I understand that this application is not intended to create any contractual or other legal rights. It does
not alter the at-will employment status nor does it create an employment contract for any specific period
of time.
I certify that I have made no willful misrepresentations in this application nor have I withheld information
in my statements and answers to questions. I am aware that the information in my statements and in my
application will be investigated, with my full permission, and that any misrepresentations may cause my
application to be rejected or my employment terminated.
I authorize any former employer to release to the city or its authorized representative any and all
employment record and other information it may have about my employment. I understand that the
information will be used for the purpose of evaluating my application for employment with the city. A
photocopy of this authorization shall be as valid as the original.
I understand that this appointment will be at the discretion of the department head concerned; subject
to the approval of the Chief Administrative Officer and that this application is the property of the City of
Arkadelphia and will become a part of my file if I am accepted for employment.
Signature of Applicant:
___________________________________
Date:
_________________
Submit Application
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