Fillable Fire Rescue Background Questionnaire (Walton County Board of Commissioners)

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Fire Rescue Background Questionnaire (Walton County Board of Commissioners)

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BROWSE WALTON COUNTY BOARD OF COMMISSIONERS (GA) FORMS

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Walton County Fire Rescue
Applicant Questionnaire
Revised: 01/2020
Walton County Fire Rescue
Walton County Civil Service Personnel Rules and Regulations
Recruitment and Selection
1. Objective - The policy of Walton County is to hire individuals based on merit and
fitness, free of personal and political consideration as determined by standards of
education, experience, aptitude, and character. All decisions regarding the recruitment,
selection, and placement of employees are made on the basis of job related criteria,
and the needs of the County.
2. Equal Employment Opportunity - Equal opportunities for employment, promotion, and
other personnel transactions shall be offered on a non-discriminatory basis without
regard to race, color, religion, national origin, gender, age, or disability. It is the policy of
Walton County to select, develop, and promote employees based on individual ability
and job performance.
Walton County Fire Rescue
Applicant’s Questionnaire
(Please print or type all responses. All questions should be answered completely)
Position Applied For:
Fulltime: ________ Yes ________ No
Temporary: ________ Yes ________ No
Volunteer: ________ Yes ________ No
A. Personal Information
1. Name:
(First) (Middle) (Last)
2. Date of Birth:
3. Place of Birth:
City State Country
4. Are you a legal US citizen? ________ Yes ________ No
5. Social Security Number:
6. Height: Weight:
7. Hair Color: Eye Color:
8. Address:
(Number) (Street) (Apartment #)
(City) (State) (Zip Code)
(Home Phone) (Cell Phone) (Business Phone)
9. Marital Status: ________ Single ________ Married
________ Separated ________ Divorced
10. If Married, the Address of your Spouse, if different from yours:
(Number) (Street) (Apartment #)
(City) (State) (Zip Code)
(Home Phone) (Cell Phone) (Business Phone)
11. Emergency Contact (someone not in your immediate household):
(Number) (Street) (Apartment #)
(City) (State) (Zip Code)
(Home Phone) (Cell Phone) (Business Phone)
12. Have you ever been arrested? ____ Yes ____ No. If Yes Explain
Date Charged Disposition of Case Arresting Agency
B. Education:
13. Circle the Highest Year Completed:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
High School Equivalency? _____ Yes _____ No
High School Graduate? _____ Yes _____ No
High School Name:
Address:
Year Graduated:
College Graduate? _____ Yes _____ No
College Name:
Address:
Year Graduated:
Degree/Course of Study:
Vocational/Technical School Graduate? _____ Yes _____ No
School Name:
Address:
Year Graduated: Degree/Course of Study:
C. Employment
14. What is your present occupation or calling?
15. Do you have any relatives who work with this department? _____ Yes _____ No
If yes, list their name(s) and your relationship:
16. Are you leaving your current job for this position? _____ Yes _____ No
If yes, explain why you are leaving:
17. Have you ever been reprimanded for being late or absent? _____ Yes _____ No
If yes, explain:
18. Have you ever been reprimanded for misconduct or not doing your job?
_____ Yes _____ No If yes, explain:
19. Have you ever had arguments concerning job duties or working conditions?
_____ Yes _____ No If yes, explain:
20. Have you ever experienced shift work? _____ Yes _____ No
If yes, explain:
D. Work Safety
21. Have you ever been disciplined for unsafe work practices, or unsafe operations of
tools, vehicles, or other equipment? _____ Yes _____ No
If yes, explain:
22. Have you ever injured yourself or another person on the job due to improper or
unsafe work practices or unsafe operation of equipment? _____ Yes _____ No
If yes, explain:
E. Military
23. Have you ever served in the military or naval organization of the United States?
_____ Yes _____ No
Branch Dates Highest Rank Service Number
24. What type of discharge did you receive?
25. Are you, or have you, been a member of the National Guard or Reserves?
_____ Yes _____ No If yes, give details:
26. Has any disciplinary action been taken against you while a member of any military
organization? _____ Yes _____ No If Yes, give details:
27. Are you still on active status in the National Guard or Reserve?
_____ Yes _____ No
Branch Rank Location
H. Driving Record
28. Do you have a current driver’s license? _____ Yes _____ No
License Number Class State Expiration Date
29. Have you ever received any traffic citations? _____ Yes _____ No
If Yes, give details:
30. Have you ever been involved in a vehicle accident? _____ Yes _____ No
If Yes, give details:
31. Has you license ever been suspended or revoked? _____ Yes _____ No
If Yes, give details:
I. Training
32. Are you currently a certified firefighter in the State of Georgia? _____ Yes _____ No
If yes, what is your certification number?
33. Do you currently possess any of the following certifications? (check all that apply)
____ N.P.Q. FF 1
____ N.P.Q. FF 2
____ Hazmat Awareness
____ Hazmat Operations
____ Hazmat Technician
____ Fire Instructor 1
____ Emergency Medical Technician
____ Paramedic
34. List any certifications, special classes attended, seminars, etc. that you
have attended or achieved. PLEASE DO NOT ATTACH COPIES
J. Attachments
Please include photocopies of the following documents to attach to this
questionnaire:
1. A copy of your High School Diploma or GED Certificate
2. A copy of your Birth Certificate
3. A copy of your Citizenship Papers (if applicable)
4. A copy or your Social Security Card
5. A copy of form DD-214 (current and former Military Personnel only)
6. A color copy of your current drivers license
7.
Copy of your current EMT or Paramedic License and CPR card
WALTON COUNTY FIRE RESCUE
REFERENCE RELEASE STATEMENT
I authorize the addressed individual, company or institution to furnish Walton County
Fire
Rescue with any information they may have concerning me, which they have on record
or
otherwise. I also release such individual, company, or institution and Walton County Fire
Rescue from any and all liability for any damage whatsoever incurred in furnishing
such
information. A photocopy of my signature on this page will suffice as an original.
Printed Name of Applicant Social Security Number
Signature of Applicant Date of Signature
Applicant—do not write below this line
To:
From:
Att:
Phone:
Fax:
The job applicant named above has applied for employment with Walton County Fire Rescue and
lists your organization as a present or previous employer. We would very much
appreciate your
help and cooperation by candidly evaluating this applicant’s performance while
employed by
your organization. You may return this form to us by mail (address above), by fax,
or call our
representative named above.
P
lease
rate
the
followin
g
Excellent
Good
Fai
r
P
oo
r
Responsiveness to Supervision

Cooperation

Qualit
y

Quantity of Work

T
imeliness o
f
Work

Attendance/Punctualit
y

Dates of employment: from: to: Position:
Reason for leaving:
Would you reemploy? If not, why not?
Other pertinent comments:
Completed by: Date:
**********Thank you for your time and cooperation**********
AUTHORITY TO RELEASE INFORMATION
To Whom It May Concern:
I hereby authorize Walton County Fire Rescue, or other authorized
representative of Walton County Fire Rescue bearing this release, or
copy
thereof, within one year of its date, to obtain any information in your files
pertaining to my employment and/or educational records; including, but not
limited to, academic achievement, attendance, athletic, and disciplinary
records.
I hereby direct you to release such information upon request of bearer.
This release is executed with full knowledge and understanding the information
is for the official use of Walton County Fire Rescue. Consent is granted for
Walton County Fire Rescue to furnish such information as is described above,
to third parties in the course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such records, and any school,
college, university, or their education institution, or other consumer reporting
agency, or retail business establishment including its officers, employees, or
related personnel, both individually or collectively, from any and all liability for
damages of whatever kind; which may at any time result to me, my heirs,
family or associates because of compliance with this authorization and request
to release information, or any attempt to comply with it.
Should there be any questions as to the validity of this release, you may
contact me at the address indicated below.
I understand my application will be subject to verification through a
comprehensive background investigation.
Falsification and/or misrepresentation of facts during any phase of the
employment process will be grounds for termination of applicant’s employment
process and/or dismissal.
****************************************************************************************
FULL NAME:
Please Print or Type
FULL NAME:
Signature
SOCIAL SECURITY NUMBER:
PHONE NUMBER:
CURRENT ADDRESS:
NOTARY PUBLIC:
Must Have Signature, Date, and Seal
Applicant’s Certification and Agreement
Authorization to Release Information
Conditions of Employment
I hereby declare the information provided by me in this application is true and
complete, and I understand that misrepresentations, omissions of facts, or
falsifications of this information are grounds for refusal to hire, or if hired,
termination.
I authorize any persons or organizations to give you any and all information
concerning my previous employment, education, or any other information they might
have, personal or otherwise, with regard to any of the subjects covered by this
application. I also release all such parties from all liability for any damage, which may
result from furnishing such information to you.
I authorize you to request, receive, and verify all information given in this application.
If I am employed by Walton County Fire Rescue, I agree to conform to the policies,
rules, and regulations of the government set forth in Walton County Fire Rescue SOG,
Walton County employee handbook, policies, and ordinances; and acknowledge that
these policies, rules, and regulations may be changed, interpreted, withdrawn, or
added to by the employers at any time, at the employer’s sole option.
I further acknowledge that if I become employed with Walton County Fire Rescue, my
employment will be at-will and may be terminated with or without cause at any time
by me or by the employer until I become a non-probationary, regular employee.
If required by Walton County Fire Rescue for the position I am applying, I consent to
undergo a physical examination, after I have been offered employment, as deemed
necessary.
THIS APPLICATION WILL REMAIN ACTIVE FOR 180 DAYS ONLY, UNLESS
RENEWED PERSONALLY BY ME IN WRITING.
Before an applicant can be selected for employment with Walton County Fire Rescue,
he/she must submit to a drug test. Should you be offered a job with Walton County Fire
Rescue, your position may require random drug testing.
May we contact your present employer? No Yes N/A
You must sign the “Authorization to Release Information” form to enable us to contact
prior employers, even though we may not contact your present employer.
Date: Signature:
Walton County Fire Rescue Consent Form
I hereby authorize Walton County Fire Rescue to receive any criminal
history record information pertaining to me, which may be in the files of any
state or local criminal justice agency in Georgia.
Full Name Printed
Street Address
City State
Zip
Sex Race Date of Birth Social Security Number
Signature
Notary Signature Date
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Fire Rescue Background Questionnaire (Walton County Board of Commissioners)

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Completed 18 July 2020

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