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Hillsborough County Fire Rescue (Hillsborough County)

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  • 195 other fields

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Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
1 of 10
Application For Reserve Responder
Full Name:
Date Submitted:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
State
ZIP Code
Phone:
Email
Name As It Appears On Driver’s License:
Driver’s License #: State Issued:
Expiration Date:
Citizenship
Are you a citizen of the United States?
YES
NO
If no, are you authorized to work in the U.S.?
YES
NO
Have you ever worked for this organization?
YES
NO
If yes, when?
Emergency Contact Information
Full Name:
Relationship:
Last
First
Phone:
Email
:
Education
High School:
Address:
From:
To:
Did you graduate?
YES
NO
Diploma:
College:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
Other:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
2 of 10
References
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Employment History
Current
Employer:
Phone:
Address:
Supervisor:
Position:
# Of Years:
Responsibilities:
May we contact your supervisor for a reference?
YES
NO
Previous
Employer:
Phone:
Address:
Supervisor:
Position:
# Of Years:
Responsibilities:
Reason For Leaving:
May we contact your previous supervisor for a reference?
YES
NO
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
3 of 10
Military Experience
(Attach Copy Of DD214)
Branch:
From:
To:
Rank:
Group:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Other Experience
Firefighting, Medical, or Public Experience
(Please List Below)
Certificates
(Check All That Apply)
FireFighter I
State #:
Date Obtained:
FireFighter II
State #:
Date Obtained:
EMT
State #:
Date Obtained:
Paramedic
State #:
Date Obtained:
Other (Write In)
State #:
Date Obtained:
(Please Attach Copies Of Certifications To This Application)
Criminal History
In answering the next questions, you may omit minor traffic violations and any offense committed as a minor,
which was adjudicated in a juvenile court or under a youth offender law. The nature, severity, and date of any
convictions will be considered in relation to the duties of the position for which you are applying.
1. Have you ever pled guilty, been convicted of OR pled nolo
contendere to any crime as an adult, other than minor traffic
violations?
YES
NO
If “Yes”, please explain:
2. Do you currently have any law violations against you?
YES
NO
If “Yes”, please explain:
3. Have you ever been a defendant in a civil action for an
intentional tort?
YES
NO
If “YES”, indicate the nature of the intentional tort and the disposition of the action.
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
4 of 10
Relative Information
Do you presently have relatives employed with Hillsborough
County Fire Rescue?
YES
NO
A “YES” to this question will not bar you from being a Reserve Responder, nor does it imply preferential
consideration. Please list any relatives currently employed with HCFR below.
Name
Relationship
Station Assignment
Why Do You Want To Become A Reserve Responder?
Please explain below in your own words, why you would like to become a Reserve Responder with Hillsborough
County Fire Rescue.
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
5 of 10
Disclaimer And Signature
I understand that fire-rescue work is very dangerous and I am fully aware that there is a risk of serious injury or
harm. I understand by my signature below, that falsification of any part of this application is cause for immediate
dismissal and may disqualify me for possible future employment with Hillsborough County Fire Rescue. I do
certify that all statements are true and correct. I understand that Hillsborough County Fire Rescue can terminate
my participation as a Reserve Responder for any reason. I understand and agree to submit to an initial medical
and physical examination as well as drug screen. I also understand and submit to the random drug screening
conducted by Hillsborough County Fire Rescue at the department’s expense, while I am a Reserve Responder. I
further understand that any and all equipment, uniforms, and protective clothing that are issued to me shall be
maintained in good working condition and shall be returned promptly after termination of my Reserve Responder
service.
Applicant
Signature:
Date:
Witness
Signature:
Date:
For Office Use Only
Date Application Received In Headquarters:
Interview Date:
Interviewing Officer:
Approved
Not Approved
Notes
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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6 of 10
Release Of Employment Information
IMPORTANT!!
I acknowledge by my signature that I have read and understand the following:
Only information contained in this application and related information submitted with this application will
be used to evaluate my qualifications. Resumes or information contained on other than Hillsborough
County Fire Rescue Reserve Responder application forms are not accepted used or provided to others.
Qualifications and Reserve Responder considerations by Hillsborough County Fire Rescue are based
upon the truthfulness and completeness of the statements in this application. Falsification or omission of
information is grounds for disqualification or dismissal. Presenting any false document(s) to gain a
Reserve Responder position may be cause for ineligibility for approval or immediate dismissal.
I authorize Hillsborough County and Hillsborough County Fire Rescue to investigate the truthfulness of all
statements made on this application and to contact my former employers and other listed references or
other persons who can verify information.
I give my consent for all contacted persons, including former employers, to provide information
concerning this application and I release each person from liability for providing such information. I waive
all causes of action that might arise from the foregoing.
On submission, this application and related information become the property of Hillsborough County Fire
Rescue and according to Florida Statute 119, are matters of public record subject to release to other
persons or agencies, upon request.
I hereby consent to the use of my social security number for County business. Disclosures of social
security numbers are required for Reserve Responder consideration. Hillsborough County Fire Rescue
collects and uses social security numbers to include, but not limited to, the following reasons: Identity
verification, background and criminal history checks; drug screening; verification of educational
credentials, prior military service and past employment; Hillsborough County government Reserve
Responder status verification; connection with other employment/Reserve Responder related databases,
I-9 verification, new Reserve Responder approval and separation reporting; Workers Comp reporting; and
any other legitimate Reserve Responder related purposes.
A post-approval offer physical examination (NFPA1582) and/or drug and alcohol testing may be required
as a condition of serving as a Reserve Responder.
I am aware that Hillsborough County Fire Rescue Reserve Responder personnel are placed on a
minimum 6 months initial probationary period, during which time either Hillsborough County Fire Rescue
or I can terminate my service, with or without cause, and with or without notice, at any time.
I am satisfied with the contents of this application and understand that once I submit my application for
this recruitment, I cannot edit it later.
Applicant
Signature:
Date:
Witness
Signature:
Date:
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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7 of 10
Tobacco Affidavit
I,
do hereby affirm that I have not been a user of Tobacco or Tobacco products for at least one (1) year preceding
my association with Hillsborough County Fire Rescue as a Reserve Responder, in accordance with Section
633.34(6), Florida Statutes.
Dated And Signed This
Day Of
, 20
Applicant Signature:
Date:
Witness Signature:
Date:
Witness Name Printed:
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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8 of 10
Reference Affidavit
To Whom It May Concern,
has filed an application with our department to
become a Reserve Responder. As a standard procedure, we conduct a background check of each individual,
including references by people who know this individual well enough to verify his/her background. Please
complete this letter and return to Hillsborough County Fire Rescue Headquarters. We appreciate your candid
response and assistance in this referral.
Sincerely,
A Reserve Responder must possess the highest of moral standards and character. As responders are
entrusted with the public’s safety, and are often placed in situations requiring unquestionable honesty and
integrity; would you offer your personal recommendation for this applicant to be accepted as a Reserve
Responder? If “YES”, why?
Name:
Address:
City:
State:
Zip Code:
Phone:
Signature:
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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9 of 10
Reserve Responder Background Check / Investigation Disclosure & Authorization Form
By signing the release below, I hereby authorize Hillsborough County to contact any and all corporations, former
employers, educational institutions, law enforcement agencies, city, state, county, and federal courts, and military
services to release information about my background including, but not limited to, information about employment,
education, driving record, criminal record and general public records history to Hillsborough County.
In compliance with Section 119.071(5), Florida Statutes (Public Records Law) by this document the Hillsborough County Office
discloses to you that your Social Security number is requested for the purpose of applicant and employee background and
criminal history checks, identity verification, verification of past employment, new hire and unemployment reporting, processing
employment benefits, drug screening, income reporting, Worker’s Comp reporting, payroll processing and reporting and will be
used solely for those purposes.
I understand that my association with Hillsborough County is subject to satisfactory completion of a background
check/investigation, including verification of information I supplied in my application for Reserve Responder.
I release from all liability all persons, companies, and schools supplying such information. I release Hillsborough
County from and indemnify Hillsborough County against any liability whatsoever in connection with such
background investigation and the use of the results there from in the employment process. I also understand that I
will be given a copy of the background check/investigation report, should any adverse action or non-selection be
considered because of the results of the report.
I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I
fully understand the terms of this release.
Print Name:
Other Name(s) Used:
Address:
Date received Degree (if applicable):
University/School degree earned from:
Social Security #:
DOB:
Drivers License #:
DL State Issued:
(Signature Of Applicant)
(Date)
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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10 of 10
Beneficiary Designation Form
Applicant Name:
Date:
SSN#:
DOB:
Beneficiaries
1. Beneficiary:
Address:
City:
State:
Zip:
Phone #:
Cell #:
Relationship To Beneficiary:
2. Co-Beneficiary:
Address:
City:
State:
Zip:
Phone #:
Cell #:
Relationship To Beneficiary:
3. Co-Beneficiary:
Address:
City:
State:
Zip:
Phone #:
Cell #:
Relationship To Beneficiary:
Applicant
Signature:
Date:
Witness
Signature:
Date:
Witness Name Printed:
Hillsborough County Fire Rescue
Reserve Responder Program
9450 E Columbus Ave Tampa, FL 33610 │
Office: 813.272.6600 Fax: 813.272.6692
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Completed 11 February 2021

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