Fill - Free fillable Jackson Hole Fire/EMS Jackson, Wyoming (Teton County Wyoming Government) PDF form

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Jackson Hole Fire/EMS

Jackson, Wyoming

APPLICATION FOR MEMBERSHIP

PERSONAL INFORMATION

Name:

Last First Middle

Mailing Address:

City State Zip

Physical Address:

City State Zip

E-Mail Address:

Phone:

Home Work Mobile

Are you over 21 years of age?  Yes  No

EMERGENCY CONTACT INFORMATION

The information that you provide in this section will be used ONLY in the event of your serious injury or death.

Family or friends you would like the department to contact. Please list in the order you want them. Note: If the

contact is a minor child, please indicate the name of the adult to contact. If needed, provide additional names on the

back of this sheet.

Name: Relationship:

Home Contact Information:

Address

Home Phone Mobile Phone

Work Contact Information:

Name of Employer

Address

Phone

PLEASE DELIVER APPLICATION TO:

JACKSON HOLE FIRE/EMS ADMINISTRATION OFFICE

40 E. PEARL AVE. (307) 733-4732

OR MAIL TO P.O. BOX 901

JACKSON WY 83001

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GENERAL INFORMATION

Do you have a valid Wyoming Drivers License?  Yes  No State:

Class: ____________ License Number: ___________________ Expiration:

List any previous Fire/EMS experience:

List any certifications that you have:

List any experiences, skills or qualifications that might benefit our organization:

Can you leave work for emergency calls?  Yes  No

Have you ever been convicted of a crime?  Yes  No If Yes, please explain.

Include date, place and nature of crime:

(Convictions will not necessarily disqualify an applicant.)

EMPLOYMENT HISTORY

(List present or most recent positions first)

1. Employer: __________________________________ Address:

Supervisor: _______________________ Phone No: ________________ Position:

Date Employed (Day, Mo., Yr): ___________________ Date Left (Day, Mo., Yr.):

2. Employer: __________________________________ Address:

Supervisor: _______________________ Phone No: ________________ Position:

Date Employed (Day, Mo., Yr): ___________________ Date Left (Day, Mo., Yr.):

3. Employer: __________________________________ Address:

Supervisor: _______________________ Phone No: ________________ Position:

Date Employed (Day, Mo., Yr): ___________________ Date Left (Day, Mo., Yr.):

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PERSONAL REFERENCES (Do not list former employers or relatives)

Name

Occupation

Address

Phone: Work/Home

PREVIOUS ADDRESS (Give Addresses for the past five years)

Street

City

State

PLEASE READ CAREFULLY

I hereby certify that to the best of my knowledge and belief the answers given by me to the foregoing questions and all

statements made by me in the application process are accurate and are subject to verification. I authorize all previous

employers and listed references to furnish whatever information they may have regarding my employment and my

reason for leaving. I understand that I may be refused membership by giving false or misleading information in my

application or interview(s), or in the event of membership to the organization, I may be immediately discharged. I

understand that as a part of the application process, I am subject to a criminal background investigation

and a health

physical. I understand that additional personal data will be required to determine if I am eligible for benefits and for

statistical/governmental reporting purposes. I also understand

that proof of U.S. permanent residency or authorization to

work in the U.S. is required upon membership/employment decision and further understand that this application is not

intended to be a contract for employment.

I understand and acknowledge that membership begins upon my appointment by the Fire Chief, and that I am required

to abide by all rules, regulations, bylaws and standard operating policies of the Ja

ckson Hole Fire/EMS Department. I

understand that I will be on probation for twelve (12) months starting from my appointment date, which includes, but is

not limited to, attendance of all meetings, regular maintenance and training meetings all as set forth by the department. I

understand that worker’s compensation, eligibility to the Wyoming Retirement System, AFLAC and Firefighter I testing

time will all start upon my appointment.

__________________________

Date Applicant’s Signature

click to sign

signature

click to edit

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Internal Use Only

⁭ Application Received Date:

⁭ Criminal Background Check

Date Sent: Date Approved:

Letter of acknowledgement sent to Applicant on

Date

Met with Chief on

Date

Application sent to Officers at Station # on

Date



Accepted  Not Accepted

Physical Date Approved:

Work Capacity Test Date Approved:

Orientation Date Approved:

Appointment with Admin for Enrollment Date:

Comments:

Revised 02/25/2013

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Fillable Jackson Hole Fire/EMS Jackson, Wyoming (Teton County Wyoming Government)

Fill Online, Printable, Fillable, Blank Jackson Hole Fire/EMS Jackson, Wyoming (Teton County Wyoming Government) Form

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