OXFORD FIRE DEPARTMENT

AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT APPLICATION

THE OXFORD FIRE DEPARTMENT IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE IN HIRING OR EMPLOYMENT ON THE BASIS OF RAC, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, HANDICAP, MARITAL STATUS, OR VETERAN STATUS.

INSTRUCTIONS:

PLEASE FURNISH COMPLETE AND ACCURATE INFORMATION. APPLICATIONS WILL BE VERIFIED. INCOMPLETE OR ILLEGIBLE APPLICATIONS WILL NOT BE CONSIDERED. BE SURE TO SIGN THE APPLICATION AFTER READING THE STATEMENT AT THE END OF THIS APPLICATION FORM. IN ADDITION TO COMPLETING THIS FORM, YOU MAY ATTACH A RESUME DETAILING YOUR PROFESSIONAL AND EDUCATIONAL BACKGROUND.

POSITION APPLIED FOR ______________________________________

PERSONAL INFORMATION

DATE OF APPLICATION: ____________

NAME: _________________________________________ ________________________

(LAST) (FIRST) (MIDDLE) SOCIAL SECURITY NO.

ADDRESS: _______________________________________ _________________________

(NUMBER) (STREET) (APT) HOME TELEPHONE NO.

_______________________________ ________________________

(CITY) (STATE) (ZIP) WORK TELEPHONE NO.

OTHER NAME(S) UNDER WHICH YOU ATTENDED SCHOOL OR WERE EMPLOYED: _________________________________________________________

AGE: ARE YOU OVER 18? Yes _______ No _______

DO YOU HAVE ANY RELATIVES CURRENTLY EMPLOYED WITH THE DEPARTMENT: YES _________ NO ________, IF YES, PLEASE LIST

____________________________________________________________________________________

NOTE: FIRE DEPARTMENT APPLICANTS MUST HAVE AND MAINTAIN A GOOD DRIVING RECORD, PLEASE COMPLETE THE FOLLOWING:

DO YOU POSSESS A VALID MICHIGAN DRIVER’S LICENSE? YES ______ NO _______

MICHIGAN DRIVER’S LICENSE NUMBER: ____________________________________________

(DRIVING RECORD WILL BE VERIFIED FOR THOSE POSITIONS REQUIRING OPERATING DEPARTMENT VEHICLES)

ARE YOU ABLE TO PERFORM THE ESSENTIAL JOB FUNCITONS AS SPECIFIED IN THE VACANCY ANNOUNCEMENT FOR THE POSITION YOU ARE APPLYING FOR? YES ______ NO_____. IF NO, PLEASE EXPLAIN ____________________________________________________

HAVE YOU EVER BEEN CONVICTED OF A CRIME, EXCLUDING MINOR TRAFFIC CHARGES, WHICH HAS NOT BEEN ANNULLED OR EXPUNGED OR SEALED BY A COURT? YES ________ NO __________. IF YES, EXPLAIN FULLY, INCLUDING DATES, NATURE OF THE OFFENSE AND DISPOSITION _________________________________________________________________________________________________

NOTE: RESPONSES TO THIS QUESTION WILL BE VERIFIED, SOME POSITIONS REQUIRE A CRIMINAL RECORDS CHECK THROUGH THE FBI, CONVICTION OF A CRIME WILL NOT AUTOMATICALLY DISQUALIFY YOU FROM CONSIDERATION.

HAVE YOU EVER BEEN DISCHARGED OR REQUESTED TO RESIGN FROM ANY POSITION?

YES _______ NO _______ IF YES, PLEASE EXPLAIN _________________________________________________

ARE YOU A UNITED STATES CITIZEN, OR, IF NOT, DO YOU HAVE A LEGAL RIGHT TO REMAIN PERMANENTLY IN THE U. S.? YES _______ NO ______

HAVE YOU EVER SERVED IN THE ARMED FORCES? YES _____ NO _____ IF YES, COMPLETE THE FOLLOWING:

DATES: FROM ___________ TO _____________ RANK AT SEPARATION ________________________________

BRANCH OF SERVICE _____________________ HIGHEST RANK HELD _________________________________

TYPE OF DISCHARGE _____________________________________________________________________________

ARE YOU NOW DEPENDENT UPON OR A HABITUAL USER OF ANY ADDICTIVE OR HALLUCINOGENIC DRUG INCLUDING, BUT NOT LIMITED TO, AMPLHETAMINES, BARBITURATES, HEROIN, MORPHINE, COCAINE, MESCALINE, LSD, STP, HASHISH, MARIJUANA, METHADONE OTHER THAN FOR MEDICAL TREATMENT UNDER THE SUPERVISION OF A LICENSED PHYSICIAN? YES _______ NO ______ IF YES, PLEASE EXPLAIN FULLY _________________________________________________________________________

__________________________________________________________________________________________________

EDUCATIONAL BACKGROUND

NAME OF GRADUATE IF NOT, DEGREE/

SCHOOL CITY/STATE YES/NO LAST GRADE CREDIT

HIGH SCHOOL ____________________________________________________________________________________

COLLEGE ________________________________________________________________________________________

COLLEGE ________________________________________________________________________________________

OTHER ___________________________________________________________________________________________

PLEASE LIST ANY HONORS OR AWARDS OR SPECIAL ACTIVITES WHILE IN SCHOOL: ______________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

EMPLOYMENT BACKGROUND

PLEASE LIST PERIODS OF EMPLOYMENT IN SEQUENCE BEGINNING WITH YOUR CURRENT OR MOST RECENT POSITION:

CURRENT OR

MOST RECENT POSITION ___________________________ CURRENT BASE PAY $ _______ PER _____

FROM ___/___ EMPLOYER __________________________ AVG HRS WORKED PER WEEK ________

MO YR ADDRESS ___________________________ CITY ___________ STATE ________________

BRIEFLY DESCRIBE DUTIES _____________________________________________________________

TO ___/___ SUPERVISOR ________________________________ TELEPHONE __________________

MO YR REASON FOR LEAVING ______________________________________________________

NEXT PREVIOUS

POSITION POSITION ___________________________ CURRENT BASE PAY $ _______ PER _____

FROM ___/___ EMPLOYER __________________________ AVG HRS WORKED PER WEEK ________

MO YR ADDRESS ___________________________ CITY ___________ STATE ________________

BRIEFLY DESCRIBE DUTIES _____________________________________________________________

TO ___/___ SUPERVISOR ________________________________ TELEPHONE __________________

MO YR REASON FOR LEAVING ______________________________________________________

NEXT PREVIOUS

POSITION POSITION ___________________________ CURRENT BASE PAY $ _______ PER _____

FROM ___/___ EMPLOYER __________________________ AVG HRS WORKED PER WEEK ________

MO YR ADDRESS ___________________________ CITY ___________ STATE ________________

BRIEFLY DESCRIBE DUTIES _____________________________________________________________

TO ___/___ SUPERVISOR ________________________________ TELEPHONE __________________

MO YR REASON FOR LEAVING ______________________________________________________

NEXT PREVIOUS

POSITION POSITION ___________________________ CURRENT BASE PAY $ _______ PER _____

FROM ___/___ EMPLOYER __________________________ AVG HRS WORKED PER WEEK ________

MO YR ADDRESS ___________________________ CITY ___________ STATE ________________

BRIEFLY DESCRIBE DUTIES _____________________________________________________________

TO ___/___ SUPERVISOR ________________________________ TELEPHONE __________________

MO YR REASON FOR LEAVING ______________________________________________________

OTHER INFORMATION

WHY ARE YOU INTERESTED IN EMPLOYMENT WITH THE OXFORD FIRE DEPARTMENT?

_________________________________________________________________________________________________________________

WHAT DO YOU FEEL TO BE YOUR GREATEST QUALIFICATION? _____________________________________________________

_________________________________________________________________________________________________________________

PERSONAL/PROFESSIONAL REFERENCES

PLEASE PROVIDE THE FOLLOWING INFORMATION ON THREE PERSONS WHO ARE FAMILIAR WITH YOUR QUALIFICATIONS AND CHARACTERISTICS. DO NOT INCLUDE EMPLOYERS OR RELATIVES.

NAME __________________________________________________ OCCUPATION ___________________________

ADDRESS _______________________________________________ CITY/STATE ___________ PHONE _________

NAME __________________________________________________ OCCUPATION ___________________________

ADDRESS _______________________________________________ CITY/STATE ___________ PHONE _________

NAME __________________________________________________ OCCUPATION ___________________________

ADDRESS _______________________________________________ CITY/STATE ___________ PHONE _________

CERTIFICATION

IMPORTANT – READ THE FOLLOWING CAREFULLY BEFORE SIGNING

1. I CERTIFY THAT ALL IMFORMATION CONTAINED IN THIS APPLICATION AND ATTACHMENTS HERETO IS TRUE, COMPLETE AND ACCURATE. I UNDERSTAND THAT ANY MISREPRESENTATIONS OR FUNISHING OF FALSE OR MISLEADING INFORMATION WILL RESULT IN REJECTION FROM ANY FURTHER CONSIDERATION FOR EMPLOYMENT OR, IF EMPLOYED, BE GROUNDS FOR DISMISSAL FROM EMPLOYMENT.

2. I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS CONDITIONAL UPON THE RESULTS OF AN APPROVED PHYSICAL AGILITY TEST, AND A PHYSICAL EXAMINATION, CONDUCTED BY A PHYSICIAN SELECTED BY THE FIRE DEPARTMENT.

3. I AUTHORIZE THE FIRE DEPARTMENT TO VERIFY AND INVESTIGATE ALL INFORMATION PROVIDED IN THIS APPLICATION AND FURTHER AUTHORIZE THOSE PERSONS AND ORGANIZATIONS NAMED THEREIN TO RELEASE INFORMATION REGARDING ME, THAT THEY MAY FULLY RESPOND TO ALL INQUIRIES CONCERNING ME AND, SPECIFICALLY, I WAIVE PRIOR WRITTEN NOTICE OF DISCLOSURE OF MY PERSONAL RECORD INFORMATION, INCLUDING ANY DISIPLINARY REPORTS, LETTERS OF REPRIMAND OR OTHER DISCIPLINARY ACTION. I ALSO AUTHORIZE EDUCATIONAL INSTITUTIONS TO RELEASE INFORMATION RELATIVE TO CLAIMED DEGREES AND ACHIEVEMENTS. IN CONSIDERATION OF THE ACCEPTANCE OF MY APPLICATION FOR EMPLOYMENT BY THE OXFORD FIRE DEPARTMENT, I HEREBY RELEASE THE DEPARTMENT, CURRENT AND PAST EMPLOYERS, EDUCATIONAL INSTITUTIONS, HEALTH CARE PROFESSIONALS AND INSTITUTIONS AND ANY OTHER PARTIES NAMED HEREIN FROM ANY AND ALL CLAIMED LIABILITY ARISING OUT OF ANY SUCH RESPONSES AND DISCLOSURES.

4. I HEREBY ACKNOWLEDGE THAT THIS APPLICATION IS FOR EMPLOYMENT OF INDEFINITE DURATION TERMINABLE AT WILL AT ANY TIME FOR ANY REASON BY MYSELF OR BY THE OXFORD FIRE DEPARTMENT. FURTHER, I UNDERSTAND THAT NO SUPERVISOR, EMPLOYEE OR ANY OTHER INDIVIDUAL OR GROUP OF INDIVIDUALS HAS THE AUTHORITY TO MAKE ANY AGREEMENT ORAL, WRITTEN OR IMPLIED OR ANY OTHER REPRESENTATION CONTRARY TO THIS.

______________________________________ _______________________

APPLICANTS SIGNITURE DATE

DO NOT WRITE BELOW THIS LINE

FOR OXFORD FIRE DEPARTMENT USE ONLY

DATE APPLICATION RECEIVED _________________

REVIEWED: APPLICATION ACCEPTED _________

APPLICATION REJECTED _________ STATE REASON(S) _________________________________________________

__________________________________________________________________________________________________________

CRIMINAL BACKGROUND CHECK DATE _____________ DRIVER’S RECORD CHECKED _____________________

DATE OF AGILITY TEST __________________ DATE OF PHYSICAL ____________________________

ORIENTATION DATE: _____________________ DATE EQUIPMENT ISSUED _______________________