Fillable Town of Hudson APPLICATION FOR EMPLOYMENT (Town of Hudson)

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Town of Hudson APPLICATION FOR EMPLOYMENT (Town of Hudson)

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Town of Hudson
Hudson Fire Department
APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER
MAIL APPLICATIONS TO:
Hudson Fire Department
C/O
Fire Administration
15 Library St.
Hudson NH 03051
(603) 886-6021 – PHONE
(603) 882-7115 – FAX
INSTRUCTIONS:
To be filled out by the applicant onl
y. If you are physically unable to fill out this
application, you may request reasonable accommod
ations in completing the form.
Answer all questions. Print neatly and accurately. Attach supplements if necessary.
Exclude any reference that may reveal or tend to reveal your race, color, religion,
national origin, creed, age, marital status, sex, sexual orientation or disability.
• Incomplete applications MAY NOT BE CONSIDERED.
• If resume is submitted, DO NOT w
rite “see resume.”
• DATE and SIGN this application.
• Please list a mi
nimum of ten years’ prior experience and education.
• Pleas
e complete this application in blue or black ink.
•
You are not required to furnish any information, which is prohibited by federal,
state or local law.
TITLE OF POSITION YOU ARE APPLYING FOR: DEPARTMENT:
________________________________________ _________________________________________
Full Time Part Time Student Intern
Grant Funded Co-op
Temporary/Limited Term Employment
TODAY’S DATE:
_________________________________________
_
Name: (Last) (First) (M.I.) Home Phone:
( ) __ __ __ - __ __ __ __
Current Address: (Street) (Apt. #)
(City) (State) (Zip Code)
Permanent Address: (Street) (Apt. #)
(if different than current address)
(City) (State) (Zip Code)
Cell Phone:
( ) __ __ __ - __ __ __ __
Can we contact you at this
number?
yes no
If yes, list hours
Are you a U.S. Citizen? yes no
Are you legally eligible for employment in the United States? yes no
When will you be available for
employment?
Are you at least 18 years of age? yes no
Your employment will be subject to verification that you meet state and federal minimum age
requirements for the type of work you are applying for and have a valid work permit.
Email Address:
yes no
Have you ever been employed by the Town of Hudson? yes no
If yes: when, in what position
, and in what department?
_______________________________________________________
Do you possess a valid Driver’s License? yes no
Do you possess a valid Commercial Driver’s License? yes no Type/class:_______________________
Do you possess any
other license? yes no Type:_______________________
_____
List any memberships in professional or technical
associations:
7/17/2015
FADMN-20 1 of 5
Can we contact you here?
Full Time
THIS SECTION MUST BE COMPLETED! Please list ALL instances in which you were convicted as an ADULT for
crimes (misdemeanors or felonies), ordinance violations, traffic violations and the like. Also, please list all criminal
charges (misdemeanors or felonies) currently pending against you. Failure to include all information requested under this
section may result in denial of employment.
CHECK HERE IF NOT APPLICABLE
Approximate dates may be listed:
Date Location Charge Court Disposition of case
NOTE: A conviction record or pending arrest record does not constitute an automatic bar to employment and will be
considered only if there is a substantial relationship to the circumstances of the particular position or if the employer
deems there is a bona fide occupational qualification inherent in the position which requires this information prior to hiring.
Did you graduate from high school? yes no
Name of school:____________________________________________________________________________________
Location of school:_____________________ If no, have you passe
d a high school equivalency or GED test: yes no
Location: ___________
______________________________________________________________________________
Special skills & qualifications – this information must be provided if you are applying for a position requiring these skills:
Experience transcribing mechanically-recorded material? yes no Typing speed (if known): ____________WPM
List any additional office equipment which you can operate skillfully:___________________________________________
________________________________________________________________________________________________
List all computer software which you can operate skil
lfully:___________________________________________
_______
________________________________________________________________________________________________
Foreign language (spoken or read with proficiency):
Frenc
h German Spanish Other:___________________________________________
_______________
Training beyond high school:
College or university, technical, nursing, business college or other schools you have attended.
College, university or school – name, location
and phone number
Presently
attending
Major
field
Type of
degree
received
Credits
earned
GPA
Describe any education or training you have had which is not covered above, such as vocational school, correspondence
courses, service schools, police academy, in-service training. Please provide dates.
IMPORTANT: You must complete the employment sections of this application. Use additional sheets if necessary. You may
attach a resume to further explain your qualifications. Please list a minimum of prior ten years’ experience and education.
Are you currently unemployed? No Yes, since ___________________________________________________
List any time periods of past unemployed
status:________________________________________________________
List any current license or registration as a
member of a trade or profession:
7/17/2015
FADMN-20 2 of 5
Applicant name_________________________
EMPLOYMENT SECTION: (Please start with your most recent position - include military service)
From (month & year) Title of your PRESENT/MOST RECE
NT position:
To (month & year) Employer’s Name (Company Name) Phone Number
Hours each week: Address:
Full time
Part time
Temporary
Name and title of supervisor:
Starting salary
(indicate yearly,
monthly or hourly):
If currently employed, may we
conta
ct that employer?
yes
no, not at this time
Reason for leaving or
considerin
g change:
Present salary
(indicate yearly,
monthly or hourly):
Number of employees you
sup
ervise:
Were you involuntarily
discharged? yes no
PRIMARY DUTIES:
From (month & year) Title of position held:
To (month & year) Employer’s Name (Company Name) Phone Number
Hours each week: Address:
Full time
Part time
Temporary
Name and title of supervisor:
Starting salary
(indicate yearly,
monthly or hourly):
Number of employees you
sup
ervised:
Were you involuntarily
discharged? yes no
Last salary (indicate
yearly, monthly or
hourly):
Reason for leaving:
PRIMARY DUTIES:
From (month & year) Title of position held:
To (month & year) Employer’s Name (Company Name) Phone Number
Hours each week: Address:
Full time
Part time
Temporary
Name and title of supervisor:
Starting salary
(indicate yearly,
monthly or hourly):
Number of employees you
sup
ervised:
Were you involuntarily
discharged? yes no
Last salary (indicate
yearly, monthly or
hourly):
Reason for leaving:
PRIMARY DUTIES:
Please use a separate sheet of paper for additional employers
7/17/2015
FADMN-20 3 of 5
OTHER EXPERIENCE
(Include volunteer experience, internships, and/or job
s, not included in the employment section.)
Company Name/Location Job Title Dates Employed (month/year) Annual salary Full or part-time
From: To:
From: To:
Additional Fire Service / EMS certifications:
EMS
Are you EMS certified
Yes No If yes, to what level:_______________________________________
Are you licenced with the National Registry Yes No If yes, what is
your registry number:__________________
What is the expiration date: ________________________
Do you have a NH EMS Provider licence: Yes
No
If yes, what is your license number: ____
______________
What is the expiration date: _________________________
Fire
Certifications with the State of New Hampshire Department of Safety: (check all that apply
)
Firefighter 1A Hazardous Materials Awareness Operations Decontamination
Firefighter 1B Driver/Operator: Apparatus with Fire Pump
Rapid Intervention Team (RIT) Incident Command System
Firefighter II Fire Officer I
Firefig hter III Fire Officer II
Are you on the current State of NH Hiring List? Yes No
Note: A copy of each certification listed above should be enclosed with this application.
_______________________________________________________________________________________________
REFERENCES
Work or education related (e.g. former employers, su
pervisors, co-workers, school faculty). No relatives/significant others.
NAME/TELEPHONE/ADDRESS
OCCUPATION
NATURE OF RELATIONSHIP
1.
2.
3.
4.
5.
Attention
: Applicants for
Firefighter
or Fire Officer positions
Please attach a separate sheet of paper and write (do not type) your answer to the following two-part question.
The answer should be at least 150 words, legible and responsive to the que
stion. What qualities make you an outstanding
candidate and what duties and responsibilities would comprise the
ideal job for you?
7/17/2015
FADMN-20 4 of 5
Applicant name_________________________
AUTHORIZATION AND CERTIFICATION
Please read and initial each of the following statements. If you have a question regardin
g any of these statements, ask the Fire Administration
Secretary for assistance prior to initialing and signing the application. Your initials and signature verify that you have read, understand and
agree to abide by these statements.
Initial:
_____ I authorize any person contacted to provide the Hudson Fire Department any and all information regarding my employment,
education and other information concerning any of the subjects covered by the application which may include, but not be
limited to, application of employment, performance evaluations, work records, excluding workers compensation if any,
wage rates, supervisors’ comments, results of any and all non-medical tests, disciplinary reports or letters, and
complaints or allegations regarding any misconduct. I agree to execute release authorization forms as required by the
Hudson Fire Department request employment records from my present and/or former employer(s). I release and hold
harmless the Hudson Fire Department, their officers, agents and employees, and the person(s) providing the information
from any liability related to the providing of this information.
Initial:
_____ I understand that after receiving a conditional offer of employment I may be required to successfully pass pre-
employment and post-employment exams to gain employment or continue employment with the Hudson Fire Deptment.
I consent freely and voluntarily to participate in required drug tests and/or a pre-employment physical exam at a location
selected by the Hudson Fire Department, and consent to the release of the test results to the Hudson Fire Department.
I hereby release and hold harmless the Hudson Fire Department, their officers, agents and employees, and the laboratory,
their employees, agents and contractors from any liability whatsoever, arising from the drug tests and/or a pre-employment
exam and decisions concerning employment based upon the results of the tests.
Initial:
_____ I authorize the Hudson Fire Department, its officers, agents, and employees to conduct a background criminal check and a
check with the Department of Transportation prior to making a decision regarding employment. I release and hold harmless
the Hudson Fire Department, their officers, agents, and employees and the person(s) providing the information from any liability
related to the performance or result of this check. I recognize that this information will be considered by the Hudson Fire
Department only if it substantially relates to the position applied for.
Initial:
_____ If accepted for employment, I agree that my status as an employee depends upon my successful performance. I
understand that just as I am free to resign at any time, the Hudson Fire Department reserves the right to terminate my
employment at any time. All employees not covered by a collective bargaining agreement are considered at-will
employees.
Initial:
_____ I agree to use such personal protective equipment and devices as may be required by the Hudson Fire Department and
to comply with safety rules and requirements. In addition, I understand that the Hudson Fire Department maintains a workplace
free from drugs, harassment and violence.
Initial:
_____ I understand that nothing contained in the application or any employee handbook, the granting of an interview, or an
offer/acceptance of employment constitutes an employment contract. I understand that no representative of the Hudson Fire
Department has the authority to make any assurances to the contrary.
I hereby certify that all statements made on or in connection with my application are true, complete and correct to the best of my
knowledge and belief. I understand and agree that any misstatements or omissions of
material fact subject me to disqualification
or, if hired, dismissal.
The Hudson Fire Department is committed to the equality of opportunity for all people. It is the policy of the Hudson Fire Department to provide equal employment
opportunities for all individuals on the basis of their skills, abilities and qualifications,
without regard to race, color, national origin, religion, political affiliation,
sex, age, disability, marital status, arrest or conviction record, sexual orientation, disabled veteran or covered veteran status, membership in the National
Guard or any other reserve component of the United States or State military forces, use or nonuse of lawful products off the employer’s premises during
non-working hours, or any other non-merit factors, except where such factors constitute a bona fide occupational qualification.
______________________________________________________ _____________________________________
Applicant’s signature Date
7/17/2015
FADMN-20 5 of 5
New Hampshire Department of Safety
DIVISION OF STATE POLICE
Central Repository for Criminal Records
33 Hazen Drive, Concord, NH 03305
SECTION I
PLEASE TYPE OR PRINT CLEARLY, ALL INFORMATION IN THIS SECTION MUST BE COMPLETED
NAME_______________________________________________________________________
LAST (MAIDEN / ALIAS) FIRST MI
ADDRESS_____________________________________________________________________
STREET CITY STATE ZIP CODE
DATE OF BIRTH_______________ HAIR COLOR_______ EYE COLOR_______ SEX________
DRIVER LICENSE NUMBER________________________________STATE_________________
PURPOSE FOR RECORD: Housing Employment Annulment/Expungement Other______________
Specify
My below signature certifies that I am the individual listed above and that the information provided is true.
YOUR SIGNATURE:___________________________________________ DATE_____________
Signed under penalty of unsworn falsification pursuant to RSA 641:3.
SECTION II
IF RECORD IS TO BE MAILED TO YOU, OR RECEIVED BY SOMEONE OTHER THAN YOURSELF,
ALL OF SECTION II MUST BE COMPLETED
I hereby authorize the release of my criminal record conviction(s), if any, to the following individual:
NAME OF PERSON / FIRM TO RECEIVE RECORD
ADDRESS______________________________________________________________________
STREET CITY STATE ZIP CODE
YOUR SIGNATURE______________________________________________DATE___________
NOTARY’S SIGNATURE_______________________________________ DATE______________
(AffixSeal) (Comm Exp.)
________________________________________________________DATE_________________
SIGNATURE OF PERSON / FIRM TO RECEIVE RECORD
NOTE: A $15.00 fee is required for each request - make checks payable to: State of NH – Criminal
Records
CRIMINAL RECORD RELEASE AUTHORIZATION FORM
✔
39 Ferry Street, Hudson, NH 03051
FADMN-45 Rev. 1/2014
TOWN OF HUDSON – FIRE DEPARTMENT
15 Library Street · Hudson, New Hampshire 03051 · Tel: 603-886-6021 · Fax: 603-594-1164
Employee Reference Release Form
Your Name: ___________________________________________________________
Address: ___________________________________________________________
___________________________________________________________
___________________________________________________________
I authorize my current and/or previous employer to furnish the Hudson Fire Department
and/or the Town of Hudson the information requested in the reference check that they may
conduct. I further promise to hold, said current and/or previous employer, its employees and
officers harmless for any statements made herein.
Social Security Number: ___________-___________-____________
Signature: _______________________________________________ Date: ____________
Please Check:
___ Yes I authorize the Hudson Fire Department and/or the Town of Hudson to
contact any of my former employers to obtain any data necessary to support
this application.
___ No
_____________________________________________________________________________
___ Yes I authorize the Hudson Fire Department and/or the Town of Hudson to
contact my present employer to obtain any data necessary to support this
application.
___ No
_____________________________________________________________________________________
RELEASE
OF
MOTOR
VEHICLE
RECORDS
(Pursuant to RSA
260:14)
Form DSMV 505 (Rev. 09/12)
NH DEPARTMENT OF SAFETY
Division of Motor Vehicles
23 Hazen Drive, Concord, NH 03305
Telephone: Driver Records/Accidents (603) 227-4040
Registration (603) 227-4030
Title (603) 227-4150
Fax (603) 271-1061 (all areas)
I. Requested Information: Are you requesting:
A. Your Motor Vehicle Record?
B. Another person’s Motor Vehicle
Record?
The back of this form must be completed and notarized.
C. Another person’s Motor Vehicle
Record as an authorized agent of
your employer or a company?
A Certificate of Authority must accompany this request, or one
must be on file with the Division of Motor Vehicles.
II. Requestor Information:
Name of
Requestor
:
Employer/Company
(If applicable):
Address:
Tele.#:
City:
State:
Zip:
III. Requested Records:
Driver Record (Certified copy): $ 15.00
Driver Record (Non-Certified copy): $ 15.00
Driver Record (Insurance copy): $ 15.00
Registration Listing (Current Information Only): $ 5.00
Registration (Certified copy): $ 15.00

Title (Certified copy): $ 15.00

Title Search (not a duplicate title): $ 20.00
License Applications and Letters of Verification: $ 15.00
Insurance Card (Accident use only): $ 1.00

Storage/Mechanics Lien (RSA 444:4-a): $ 0.00
Accident Report (Requestor will be notified of cost):
$ 1.00 per page ($5.00 minimum)
Other:
:
$
Make checks payable to “State of NH – DMV”
IV. Intended Use of Information:
IMPORTANT: To be completed only if you checked Box C above
For use in connection with any civil, criminal, administrative or arbitral proceeding.
Docket # Court: [RSA
260:14
V
(a)(2)].
By a bank or similar institution to verify the accuracy of personal information submitted by
the individual to the bank [RSA 260:14 V (a)(3)].
For providing notice to the owner(s) of a towed or
impounded vehicle
[RSA
260:14
V (a)(5)].
For use by any private
investigative agency
or
security
service licensed by this state for any
purpose permitted pursuant to RSA 260:14, V (a), other than for bulk distribution for
surveys, marketing or solicitations pursuant to RSA 260:14,V(a)(8)
[RSA
260:14V(a)(6)].
Indicate specific reason here
By an employer or its agent or insurer to obtain or verify
information
relating to a holder of a
commercial driver’s license [RSA 260:14 V (a)(7)].
By a public utility to perform its public service obligation provided the individual has given
their express consent [RSA 260:14, V (a)(9)].
For an insurance company or by its authorized agent [RSA 260:14 IV (a)(2)].
Vehicle or boat information only.
For use by a life insurance company authorized to write life insurance policies in New
Hampshire,
or its
authorized
agent. In
checking
off this box, I
represent
that the named
person’s written consent to the release of the record has been obtained and that the
record will be used solely in connection with claims investigation, rating, and
underwriting. [(RSA 260:14, V(a)(10)]
(Initial here)
V. Search For (provide all applicable information):
Name:
Date
of
Birth:
Registration/Plate
#:
Driver
License/I.D. #:
Vehicle
Identification
#
:
Last Known Address:
Date
of
Accident:
Location
of
Accident:
Route/Street City/Town
Other
Identification
Information:
***Reverse Side Must Be Completed Before Processing***
Hudson Fire Department
39 Ferry Street
Hudson
NH
03051
(603) 886-6021
X
XXX
VI. Signed Authorization:
If you are requesting your record be released to another person, the authorization of the person listed in
Section V “Search For
” must be acknowledged by a Notary Public or a Justice of the Peace on the back of
this form.
Notary Public / Justice of the Peace Acknowledgement:
I authorize my record to be released to a third person:
Date:
(Signature)
State of , County of: ss
Date:
The
above named
personally appeared
and made oath
that the above declaration by him is true.
In witness whereof I hereunto set my hand and official seal:
Notary Public/Justice of the Peace Commission Expiration
Certification:
I have read RSA 260:14 and I understand the
limitations placed on the use of information
received by the Department of Safety. This form
is signed under penalty of unsworn falsification
pursuant to RSA 641:3 and subject to the
penalties specified in RSA 260:14, IX.
Signature of Requestor
Date:
VIII. PENALTY CLAUSE:
RSA 260:14, IX states as follows:
(a) A person is guilty of a class B
misdemeanor
if such person
knowingly
discloses
information
from a
department
record
to a person known by such person to be an unauthorized person; knowingly makes a false representation to obtain
information
from a
department record;
or
knowingly
uses such
information
for
any
use other than the use
authorized
by the
department. In addition, any professional or business license issued by this state and held by such person may, upon
conviction and at the discretion of the court, be revoked permanently or suspended. Each such unauthorized disclosure,
unauthorized use or false representation shall be considered a separate offense.
(b) A person is guilty of a class B
felony
if, in the
course
of
business,
such
person knowingly
sells, rents, offers, or exposes
for sale motor vehicle records to another person in violation of this section.
OFFICIAL USE
ONLY
Date
Received:
Date
Sent:
Type of Identification: Valid Photo Driver License
State-issued Photo ID
Valid Military Identification
Valid Passport
Birth Certificate
Other
(specify)
ID
Number
Employee Verifying Applicant Identification (Print Name) Signature
-----------------------------------------------DO NOT WRITE BELOW THIS LINE----------------------------------------------
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Town of Hudson APPLICATION FOR EMPLOYMENT (Town of Hudson)

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Completed 23 January 2021

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