Fillable Jrc-fillable-application-2019 CENTRAL OREGON FIRE AGENCIES

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Jrc-fillable-application-2019 CENTRAL OREGON FIRE AGENCIES

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U.S.A. forms for Central Oregon Community College

BROWSE CENTRAL OREGON COMMUNITY COLLEGE FORMS

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1
CENTRAL OREGON FIRE AGENCIES - JOINT RECRUITMENT SCHOLARSHIP
APPLICATION PROCESS
Full Name of Applicant: ___________________________________
• COCC is an unbiased neutral party. The testing process is that of the Central Oregon Fire
Agencies NOT Central Oregon Community College (COCC). COCC provides the logistical facilitation
and is an unbiased holder of the paperwork.
Initial ________
• Selections and Scholarship awards will be made by the fire agencies as a collaborative effort.
Selections will be made by the department representatives based on your performance and ranking in all the
testing areas. The final decision for your scholarship will be made solely by the Fire Chief or Designee of the Fire
Department that has chosen you.
Initial ________
• By choosing any of the departments, you are NOT guaranteed a position within the
departments and you are NOT guaranteed a scholarship with any of the departments.
Initial ________
• INCOMPLETE applications will NOT be accepted! Your release & liability paperwork must be returned
prior to due date or application will not be accepted.
Initial ________
• I understand that I must have made contact with all the departments that I have listed as my
1
st
, 2
nd
and 3
rd
choices.
Initial ________
• I understand that a background check will be required to have been started by March 29th,
2018, prior to the testing date and that there is a cost associated with it.
Initial ________
• I understand that if I am selected by an agency, there may be additional documentation
required by the agencies specific to that agency.
Initial ________
Disclaimer: Please initial that you have Read and Understand the following:
2
CENTRAL OREGON FIRE AGENCIES JOINT AFFILIATION RECRUITMENT
Valid EMAIL is crucial for this application process! Please make sure you have included a
good phone number and email address. All correspondence regarding the testing process
will be via email.
APPLICATION PLEASE PRINT LEGIBLY!
Application Information
Full Name _____________________________________________________ Date______________
Last First MI
Address _________________________________________________________________________
________________________________________________________________________________
Phone (____)___________________ Email Address _____________________________________
Driver’s License Number ______________________________ State Issued ___________________
YES NO
Are you a citizen of the United States? ___ ___
Have you ever been affiliated? ___ ___ If so, where? ______________________
Have you ever been convicted of a felony? ___ ___
If yes, explain ____________________________________________________________________
________________________________________________________________________________
Education
High School __________________________________ City & State__________________________
YES NO
From _________ to ________ Did you Graduate? ___ ___ Degree _____________________
College _____________________________________ City & State __________________________
YES NO
From _________ to ________ Did you Graduate? ___ ___ Degree _____________________
College _____________________________________ City & State __________________________
YES NO
From _________ to ________ Did you Graduate? ___ ___ Degree _____________________
Other ______________________________________ City & State __________________________
YES NO
From _________ to ________ Did you Graduate? ___ ___ Degree _____________________
3
References
Please list 5 references with at least two (2) of them being professional references
Full Name ____________________________________Relationship _________________________
Company ____________________________________________ Phone ______________________
Address _________________________________________________________________________
Full Name ____________________________________Relationship _________________________
Company ____________________________________________ Phone ______________________
Address _________________________________________________________________________
Full Name ____________________________________Relationship _________________________
Company ____________________________________________ Phone ______________________
Address _________________________________________________________________________
Full Name ____________________________________Relationship _________________________
Company ____________________________________________ Phone ______________________
Address _________________________________________________________________________
Full Name ____________________________________Relationship _________________________
Company ____________________________________________ Phone ______________________
Address _________________________________________________________________________
Military Service
Branch ______________________________________ From ____________ To _______________
Rank at Discharge _________________________Type of Discharge _________________________
If other than honorable, explain _______________________________________________________
4
Employment History
Company _________________________________________________________ Phone _________________________
Address ____________________________________________________Supervisor_____________________________
Job Title ______________________________________________Starting Salary ___________ ending Salary_________
Responsibilities ____________________________________________________________________________________
From __________ To __________ Reason for Leaving ____________________________________________________
YES NO
May we contact your supervisor (or previous supervisor) for a reference? ____ ____
Company _________________________________________________________ Phone _________________________
Address ____________________________________________________Supervisor_____________________________
Job Title ______________________________________________Starting Salary ___________ ending Salary_________
Responsibilities ____________________________________________________________________________________
From __________ To __________ Reason for Leaving ____________________________________________________
YES NO
May we contact your supervisor (or previous supervisor) for a reference? ____ ____
Company _________________________________________________________ Phone _________________________
Address ____________________________________________________Supervisor_____________________________
Job Title ______________________________________________Starting Salary ___________ ending Salary_________
Responsibilities ____________________________________________________________________________________
From __________ To __________ Reason for Leaving ____________________________________________________
YES NO
May we contact your supervisor (or previous supervisor) for a reference? ____ ____
Company _________________________________________________________ Phone _________________________
Address ____________________________________________________Supervisor_____________________________
Job Title ______________________________________________Starting Salary ___________ ending Salary_________
Responsibilities ____________________________________________________________________________________
From __________ To __________ Reason for Leaving ____________________________________________________
YES NO
May we contact your supervisor (or previous supervisor) for a reference? ____ ____
5
Training and Education Information
If a current COCC Student, what year are you? ________________________________________
Which degree are you pursuing first, EMS or Structure Fire? ______________________________
Do you have any of the following certifications currently?
YES NO
First Responder ____ ____ If yes, date certified _________________________
EMT-Basic ____ ____ If yes, date certified _________________________
EMT-Paramedic ____ ____ If yes, date certified _________________________
NFPA Firefighter I ____ ____ If yes, date certified _________________________
NFPA Firefighter II ____ ____ If yes, date certified _________________________
NFPA Driver ____ ____ If yes, date certified _________________________
NWCG S-130/190 ____ ____ If yes, date certified _________________________
NWCG S-215 ____ ____ If yes, date certified _________________________
Hazmat Awareness ____ ____ If yes, date certified _________________________
Hazmat Operations ____ ____ If yes, date certified _________________________
NWCG or FEMA I-100 ____ ____ If yes, date certified _________________________
NWCG or FEMA I-200 ____ ____ If yes, date certified _________________________
FEMA IS-700 ____ ____ If yes, date certified _________________________
FEMA IS-800 ____ ____ If yes, date certified _________________________
List any other certifications pertinent to affiliation __________________________________________
________________________________________________________________________________
________________________________________________________________________________
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to affiliation, I understand that false or misleading information in my
application or interview may result in my release.
All information included in this packet will be kept Personal and Confidential by the Central
Oregon Fire Agencies and Central Oregon Community College Fire Program Director.
Signature __________________________________________________ Date _________________
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Completed 17 February 2020

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