Fillable Application for Employment (Town of Granville)

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Application for Employment (Town of Granville)

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The Application for Employment (Town of Granville) form is 16 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Town of Granville

BROWSE TOWN OF GRANVILLE (WV) FORMS

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Application for Employment
Granville Fire Department
1245 Main Street, Granville, WV 26534
304-599-5080
Fire Department Application
Application for Employment
(Pre-Employment Questionnaire - An Equal opportunity Employer)
Personal Information
Name:
Last
First
Middle
Maiden
Present Address:
Street
City
State
Zip
Street
City
State
Zip
Phone Number:
Alternate Phone Number:
SS#:
- -
Place of Birth:
DOB:
/ /
Are you 18 years old?
❏ Yes
❏ No
Are you a U.S. Citizen?
❏ Yes
❏ No
Are you an alien authorized to work in the United States?
❏ Yes
❏ No
Position:
Date you can start:
Salary Desired:
$
Are you employed now?
❏ Yes
❏ No
Have you previously applied to the Town of Granville?
❏ Yes
❏ No
If so, when and for what position?
Have you worked for the Town of Granville?
❏ Yes
❏ No
If yes, fill in reason for leaving and dates of employment:
Service Record
Branch of Service:
Discharge Date/ Rank:
Present Membership in National Guard/Reserves?
❏ Yes
❏ No
Date Obligation Ends:
/ /
Type of discharge:
Prior Courts Marshall?
❏ Yes
❏ No
Application for Employment
Education
School Level
Name and Location
# Years
Attended
Did you
Graduate?
Subjects
Studied
High School
College
Trade/Business
or
Correspondence
Work Experience (Past 10 years. More than two - please attach)
Name of Employer:
Address:
Street
City
State
Zip
Starting Date:
/ (mm/yyyy)
Leaving Date:
/ (mm/yyyy)
Weekly Starting Salary:
Weekly Final Salary:
Job Title:
May we contact your supervisor?
❏ Yes
❏ No
Name/Title of Supervisor:
Phone No.:
Description of Work:
Reason for Leaving:
Name of Employer:
Address:
Street
City
State
Zip
Application for Employment
Starting Date:
/ (mm/yyyy)
Leaving Date:
/ (mm/yyyy)
Weekly Starting Salary:
Weekly Final Salary:
Job Title:
May we contact your supervisor?
❏ Yes
❏ No
Name/Title of Supervisor:
Phone No.:
Description of Work:
Reason for Leaving:
References (Provide 2 each of Personal and Professional of persons not related to you.)
Personal
Name
Address
Phone
Number
Business
Years
Known
Professional
Name
Address
Phone
Number
Business
Years
Known
Application for Employment
Authorizations
“I certify that the facts contained in this application are true and complete to the best of my
knowledge and understand that, if employed, falsified statements on this application shall be
grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to
give you any and all information concerning my previous employment and any pertinent
information they may have, personal or otherwise, and release all parties from all liability for
any damage that may result from furnishing same to you.
I understand and agree that, if hired, my employment is for no definite period, and may,
regardless of the date of payment of my wages and salary, be terminated at any time without
any prior notice.”
_______________________________________ _____________________________
Applicant Signature Date
I do hereby authorize and give my permission to the Veterans Administration, all US Military
Services, R.O.T.C. and Reserve doctors, insurance companies, state and federal income tax
bureaus, past and present employers, any criminal justice agency, credit bureau, any person
or persons named in this application, and any other agency, corporation or organization to
furnish to the Town of Granville representative with any and all available information regarding
me in order that they may determine my suitability for police services. I release them from any
and all liability whatsoever for furnishing the aforementioned information.
_______________________________________ _____________________________
Applicant Signature Date
I understand to assure that an adequate number of personnel are available at all times and
that all off duty fire fighters will be available for call back within a reasonable response time in
emergency situations, the Town finds it necessary to require that its fire fighters reside no
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Application for Employment
further than a specified distance from their workplace. The following residency requirements
shall apply.
Any fire fighter employed by the Town of Granville shall maintain a permanent physical
residence within 10 air miles of the Town Hall located at 1245 Main Street Granville, WV. The
fire fighter agrees to maintain this residency while under the employment of the Town of
Granville.
Any fire fighter that does not reside within this area at the time of his/her appointment shall
establish his/her physical residence as soon as physically possible.
Any and all disputes involving the enforcement of this rule shall be decided by the Granville
Fire Dept. hearing board.
_______________________________________ _____________________________
Applicant Signature Date
Waiver of Privacy Act - Release of Information
I, _________________________________, give the Town of Granville, its police detectives, or
any of its agents the right and permission to check any and all of my credit records. The
permission to check shall include contact with any credit bureau, bank, loan institution and
anyone with knowledge of my financial status.
I, _________________________________, give the Town of Granville, its police detectives, or
any of its agents the right and permission to check any and all agencies, medical and/or
mental health facilities, law enforcement agencies and any agency which might be of concern
for the completion of such investigation. The voluntary release form allows the police dept. to
contact agencies for release of information and accurate documentation concerning my past
personal history, employment history, criminal history, and financial history.
I, _________________________________, give the Town of Granville, its police detectives, or
any of its agents free from any liability connected with the investigation of my credit records
or financial status. This release of liability means I can take no legal action against the Town
of Granville, its detectives, or its agents regardless of the results of the investigation or how
the investigation results are used.
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Application for Employment
I, _________________________________, have read and understand the above release and give
my permission for the background investigation if considered for employments.
Application for Employment
PRIVACY ACT STATEMENT
(Date required by the Privacy Act of 1974)
*PLEASE READ CAREFULLY*
(Authority for collection of information including Social Security Number (SSN) is contained in 5 USC
23, USC 708, 44 USC 3101, 32 USC 708, and sections 133, 265, 275, 504, 508, 510, 672(d), 678,
837, 1007, 1071 through 1087, 1168, 1169, 1475 through 1480, 1553, 2107, 3012, 5031, 8012,
8033, 8496, and 9411 of 10 USC, and in Executive Orders 9397, 10450, and 11652.)
The authority for collection of information must be signed by you giving the Police
Department of the Town of Granville permission to do a thorough background investigation with
agencies such as the CREDIT BUREAU, MEDICAL AND/OR MENTAL INSTITUTIONS, LAW
ENFORCEMENT AGENCIES, and any other agencies which might be of concern for the completion
of such investigation. This voluntary release form allows the Police Department to contact agencies
for release of information and accurate documentation concerning your past personal history,
employment history, criminal history, and financial status.
Principal purpose(s): for which information is intended to be used:
To obtain background information for personnel investigative and evaluative purposes in
connection with the making of securing determinations with respect to: (1) employment with the
Town of Granville, particularly in sensitive civilian positions or for other positions that have been
designed as requiring a determination as to whether employment in or assignment to such positions
is clearly consistent with the interests of the public welfare, (2) positions of Police Officers, Fire
Fighter, or other sworn position, or (3) a position which has access to classified or protected
information.
The information will be used to determine your acceptability for employment with the Town of
Granville. The information will be principally used to determine your mental, medical, and moral
qualifications for employment with the Town of Granville. If you are accepted and subsequently hired
by a component of the Town of Granville, this information will then become a part of your personnel
record.
Your Social Security Number (SSN) is necessary to identify you and your records, and to
properly report your earnings as an employee of the Town of Granville to the Social Security
Administration, should you be hired. The data is FOR OFFICIAL USE ONLY (FOUO) and will be
maintained in strict confidence in accordance with Federal Law and Regulations.
Application for Employment
Disclosure of this information and signing of this form is voluntary. However, failure to furnish
information or the falsification of any information contained in this application for employment can
and will result in dismissal of the application.
Date of birth:
SSN:
Signed:
Date:
Received by:
Application for Employment
I, _________________________________, for and consideration of being considered for
employment by the Granville Fire Department, do hereby make the following representation
and acknowledgements:
1. As part of the application process, I will have to take a physical agility test. A copy of
the requirements will be provided to you at the time of application. You will have an
opportunity to practice these tests prior to the actual testing procedure. Regardless of
your physical condition, I recognize that there are risks of injuries involved in taking this
physical agility test. I further understand that if I am not in appropriate physical
condition, I may be placing myself at risk. Any pre-existing injuries, diseases, or
physical conditions may be aggravated by this test, I have noted here:
2. I realize and agree that while taking this agility test, I am not an employee, agent or
servant of the Town of Granville or the Granville Fire Department, and therefore will not
be covered by any worker’s compensation, death or disability benefits of the Town of
Granville.
By signing this waiver, I do hereby release and forever discharge the Town of Granville and/or
the Granville Fire Department and its officials, officers and employees, in both their public and
private capacities, from any and all liability, claims, suits, demands or causes of action that
may arise from taking the agility test. This waiver is intended to cover all acts or omissions of
the Town of Granville regardless of whether such act or omission is the result of an
intentional, reckless, grossly negligent, or negligent act. By signing this waiver, it is my intent
to bind my heirs, executors, administrators and assigns. I understand the terms of this release
are contractual and not a mere recital. Before signing this release, I have read it fully and
hereby acknowledge that I understand it and have no questions concerning the content. I
have signed this document of my own free will.
Printed Name:
Signature:
Date:
Address:
Phone Number:
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Application for Employment (Town of Granville)

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Completed 16 July 2020

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