Fillable FORT MOJAVE MESA FIRE DEPARTMENT

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FORT MOJAVE MESA FIRE DEPARTMENT

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FORT MOJAVE MESA FIRE DEPARTMENT
Employment Application
NOTICE:
1. TO BE CONSIDERED FOR EMPLOYMENT, YOU MUST ANSWER ALL QUESTIONS AND COMPLETE ALL SECTIONS OF THIS APPLICATION FORM.
2. THE DEPARTMENT EMPLOYS ONLY U.S. CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF IDENTITY AND WORK AUTHORIZATION WITHIN 3 WORKING
DAYS OF EMPLOYMENT.
3. MALES SUBJECT TO MILITARY SELECTIVE SERVICE REGISTRATION MUST CERTIFY COMPLIANCE TO BE ELIGIBLE FOR EMPLOYMENT. SEE AVAILABILITY
BLOCK.
4. EMPLOYMENT WITH FORT MOJAVE MESA FIRE DEPARTMENT IS EMPLOYMENT-AT-WILL.
WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU:
1. COMPLETE THE SECTION FOR EQUAL OPPORTUNITY INFORMATION.
2. GIVE COMPLETE INFORMATION ON YOUR EDUCATION AND WORK HISTORY (*SEE RESUME* IS NOT ACCEPTABLE).
3. LIST SEPARATELY EACH JOB HELD AND YOUR DUTIES FOR EACH POSITION WHEN YOU WORKED FOR ONE EMPLOYER AND HELD MORE THAN ONE
POSITION.
4. CHECK FOR ACCURACY, SIGN AND DATE YOUR APPLICATION.
THANK YOU FOR YOUR INTEREST IN FORT MOJAVE MESA FIRE DEPARTMENT. FORT MOJAVE MESA FIRE DEPARTMENT WANTS TO FIND THE BEST
QUALIFIED PEOPLE AVAILABLE TO SERVE ITS CITIZENS. ALTHOUGH EVERYONE WHO APPLIES CANNOT BE HIRED, YOUR APPLICATION WILL BE GIVEN
EVERY CONSIDERATION.
Exact title of position for which you are applying:
POST OFFICE BOX 8488 FORT MOHAVE, ARIZONA 86427-8488 928.768.9181 928.768.8434 (Fax)
1. LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NO. (TO BE USED AS YOUR CANDIDATE ID NO.)
2. CURRENT ADDRESS NUMBER & STREET APT. NO. CITY STATE ZIP CODE
3. PHONE (Home or Other Number Where You Can Be Reached)
4. BUS. PHONE
5. HAVE YOU EVER FILED AN APPLICATION WITH US BEFORE?
Yes No If “Yes”, give date
7. WHEN ARE YOU AVAILABLE TO BEGIN EMPLOYMENT?
8. TYPE OF EMPLOYMENT THAT YOU WILL ACCEPT:
Full Time / suppression (rotating shifts, night work, weekends)
Full Time (40 hrs/wk) Part Time
9. Have you ever been convicted of, or pled guilty or no contest to, any unlawful offense, other
than a minor traffic violation? Yes No
If “Yes”, please explain:
NOTE: A conviction record will not necessarily exclude you from employment. Factors such as
age at time of offense, rehabilitation efforts, how recent the offense was, nature of the crime and
type of job for which you are applying will be considered.
10. ARE YOU LEGALLY ELIGIBLE TO WORK IN THE UNITED STATES?
YES NO
11. IF YOU ARE SUBJECT TO SELECTIVE SERVICE REGISTRATION, ARE YOU IN
COMPLIANCE? YES NO
12. ARE YOU RELATED BY BLOOD OR MARRIAGE TO ANY PERSON
CURRENTLY EMPLOYED BY FMMFD? YES NO
If "Yes," give name of person and relationship
13. US MILITARY Have you served honorably in the Armed Forces of the United States on active duty
for a minimum of 6 months for reasons other than training? YES NO Do you wish to
declare a service-connected disability? YES NO At the time of this application, are you
the surviving spouse or dependent of a deceased veteran who died from service-related
reasons? YES NO Do you wish to declare eligibility for veteran’s preference as the
spouse of a disabled veteran? YES NO Give dates of your (or spouses) qualifying active
military service: Entered: Separated: Branch:
Rank: Are you a member of the Military Reserves? YES NO
Branch: Rank:
NOTE: To claim verteran's preference points, you must present proof of honorable discharge
(DD214) when you file your application. This also applies to current Dept. employees.
14. DO YOU HAVE
HIGH SCHOOL DIPLOMA GED
FOR OFFICIAL USE ONLY
ELIGIBILITY FOR VETERAN’S PREFERENCE: YES NO
Important Instructions: Do not e-mail or fax your application. Your signed application will only be accepted in hard
copy form with original signature. Mail this application form with the other required documents as noted in the Fire
Captain information/application packet.
15. EXPERIENCE: Beginning with your current or most recent experience (including volunteer experience), list your history, both employment and non-employment, for the last 20
years. Be specific and detailed. Account for all time lapses by indicating the dates and reason for the lapse.
FROM MO/YR
EMPLOYER (BUSINESS OR AGENCY NAME)
TITLE OF YOUR POSITION
NO. EMPLOYEES SUPERVISED BY YOU
TO MO/YR
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR
SUPERVISOR'S PHONE NO.
HRS. PER WK.
DUTIES:
SALARY:
$
PER/
REASON FOR LEAVING
FROM MO/YR
EMPLOYER (BUSINESS OR AGENCY NAME)
TITLE OF YOUR POSITION
NO. EMPLOYEES SUPERVISED BY YOU
TO MO/YR
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR
SUPERVISOR'S PHONE NO.
HRS. PER WK.
DUTIES:
SALARY:
$
PER/
REASON FOR LEAVING
FROM MO/YR
EMPLOYER (BUSINESS OR AGENCY NAME)
TITLE OF YOUR POSITION
NO. EMPLOYEES SUPERVISED BY YOU
TO MO/YR
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR
SUPERVISOR'S PHONE NO.
HRS. PER/WK.
DUTIES:
SALARY:
$
PER/
REASON FOR LEAVING
FROM MO/YR
EMPLOYER (BUSINESS OR AGENCY NAME)
TITLE OF YOUR POSITION
NO. EMPLOYEES SUPERVISED BY YOU
TO MO/YR
ADDRESS CITY STATE ZIP
NAME OF SUPERVISOR
SUPERVISOR'S PHONE NO.
HRS. PER WK.
DUTIES:
SALARY:
$
PER/
REASON FOR LEAVING
If additional space is needed for work experience, copy this form and attach.
16. NAME, CITY & STATE OF HIGH SCHOOL, COLLEGES/UNIVERSITIES ATTENDED
(STATE NUMBER OF YEARS COMPLETED)
UNITS COMPLETED
SEMESTER QUARTER
COURSE OF
STUDY/MAJOR
TYPE OF DEGREE: COMPLETED:
YES NO
17. LIST FIELDS OF WORK FOR WHICH YOU HAVE BEEN REGISTERED, LICENSED OR
CERTIFIED
STATE ISSUED CERTIFICATE NUMBER DATE ISSUED AND
EXPIRATION DATE
Registration:
Registration:
18. LIST SPECIFIC COURSES, WORKSHOPS, AND TRAINING YOU HAVE HAD THAT
RELATES TO THE POSITION YOU ARE APPLYING FOR. INCLUDE CREDIT HOURS OR CEU’S,
IF APPLICABLE.
NAME AND LOCATION OF INSTITUTION LENGTH OF COURSE ENDED
19. LIST ANY FOREIGN LANGUAGES YOU CAN SPEAK, READ OR WRITE FLUENTLY 20. DO YOU HAVE A VALID DRIVER'S LICENSE? YES NO
NUMBER: STATE EXP DATE
21. D
ESIGNATE
S
KILLS
,
I
F
R
EQUIRED FOR THIS
P
OSITION
.
(Note: Testing of skills may be required prior to Typing Speed wpm
or following selection.) Data Entry Speed wpm
F
OR
O
FFICIAL
U
SE
O
NLY
Examination Number _______________
Approved
Education Incomplete:
Disapproved Late License
Not Elg. Prom Not Elg. Restr.
Met MQs/Scrnd CSB Rule 4.12B
Exp. CSB Rule 4.07
Other ___________________________
Date Initials ________________ __________________
22. N
AME
,
A
DDRESS AND
P
HONE
N
UMBER OF
E
MERGENCY
C
ONTACT
N
AME PHONE
A
DDRESS
CITY
INQUIRY WILL BE MADE OF YOUR FORMER EMPLOYERS OR THE LAST SCHOOL YOU ATTENDED REGARDING YOUR PERFORMANCE RECORD.
MAY WE CONTACT YOUR PRESENT EMPLOYER? YES NO
C
ERTIFICATE OF
A
PPLICANT
: I certify that I have given true, accurate and complete information on this form. In the event confirmation is needed in connection with my work, I
authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize
Fort Mojave Mesa Fire Department or its agents to investigate all statements made in this application and understand that false information or documentation, or a failure to
disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand
that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications.
Date: _Signature: ______________________________________________________ ______________________
FMMFD EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE
Name: Date:
Date of Birth: Sex: Male Female
Choose the one Ethnic Group with which you most closely identify:
a. White (non-Hispanic)
b. Black (non-Hispanic)
c. Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin
regardless of race)
d. Asian (including Pacific Islander)
e. American Indian (including Alaskan native)
A. None/Prefer not to report G. Respiratory impairment
B. Blind or severely visually impaired H. Nervous system/Neurological disorder
C. Deaf or severely hearing impaired I. Mentally restored
D. Loss of limited use of arms and/or hands J. Mental retardation
E. Non-ambulatory (must use wheelchair) K. Learning disability
F. Other orthopedic impairment (including L. Others (heart disease, diabetes,
amputation, arthritis, back injury, cerebral speech impairment)
palsy, spina bifida, etc.) M. Other (please specify)
Fort Mojave Mesa Fire Department policy prohibits discrimination based
on race, sex, color, creed, national origin, age or disability. The
information requested below will in no way affect you as an applicant.
Its sole use will be to see how well our recruitment efforts are reaching
all segments of the population.
DISABILITY: *Disability means, with respect to an individual: (1) a
physical or mental impairment that substantially limits one or more of the
major life activities of such individual; (2) a record of such an impairment;
or (3) being regarded as having such an impairment* (Americans with
Disabilities Act of 1990). Persons without a disability should check item
A.
The reporting of a disability is strictly VOLUNTARY. Persons with
disabilities who DO NOT WISH to report their disabilities should check
item A. Information reported on this form will be kept confidential as
required by State law. Public disclosure of this information without your
consent would be a violation of state law.
STATE ZIP CODE
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FORT MOJAVE MESA FIRE DEPARTMENT

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Completed 3 May 2021

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