Application Form – Pleasant Hill Goshen Fire & Rescue

Pleasant Hill Goshen Fire & Rescue Volunteer Firefighter Application

PLEASANT HILL GOSHEN FIRE & RESCUE IS AN EQUAL OPPORTUNITY EMPLOYER

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General Information

Position Applying For*

Volunteer Firefighter

Resident Volunteer Firefighter

Support Services

Academy Experience:*

I have completed a fire academy.

I will need to go through the fire academy.

When and where did you complete fire academy?*

Which academy are you applying for?*

Fall

Spring

Name*

First Name Middle Name Last Name

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Do you have a legal right to work in the U.S.?*

Yes

All new hires will be required to submit verification of the legal right to work in the United States within three (3) business days beginning with their first day of work. In accordance with the Immigration Reform and Control Act of 1986, we are legally prohibited from employing anyone who cannot provide such verification. The District is not able to accommodate an HB-1 Visa.

Driver's License Information

Do you have a valid driver's license?*

Yes

Driver's License Number*

Driver's License State*

Do you have a valid CDL?*

Yes

List CDL classification and any endorsements:*

Education Information

Do you have a high school diploma or GED?*

High School Diploma

GED

Neither

Name and Location of high school:*

Name and Location where you obtained your GED:*

Have you completed any college or university course work?*

Yes

Please list all college coursework and/or degrees completed:

Name of College/University	Major	Type of Degree	Actions

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Do you have any professional registrations, licenses, and/or certifications?*

Yes

Please list any professional registrations, licenses, and/or certifications that relate to this position:

Type of registration, license, and/or certification:	License Number (if applicable)	Actions

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Maximum number of entries reached.

Do you have any specialized training and/or have attended any trade schools?*

Yes

List any specialized training and/or trade schools:*

Mililtary Service

Are you a Veteran or qualified spouse of a Veteran?*

Yes

Branch of Service*

Date of Discharge*

Please attach your DD214:*

Max. file size: 256 MB.

Work / Volunteer History

Begin with your present or most recent position. List ALL positions (paid or volunteer) over the last 5 years. Include any experience prior to 5 years ago that relates to the position. To add a new position to the list, click "Add Entry".

Employment

Position Title	Name of Business/Organization	Start Date (Month and Year)	Actions

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If you don't have 5 years of work or volunteer history, please explain why below:*

Have you ever been terminated, discharged, or resigned in lieu of termination due to misconduct or unsatisfactory service?*

Yes

Please name the employer, explain the circumstances, and date (Mo/Yr).*

Professional References

Please provide 3 professional references. Family members cannot be listed as professional references, and only friends with professional ties can. Other options: a former employer, supervisor, colleague, teacher, or client.*

References

First Name:	Last Name:	Actions

There are no References.

Maximum number of references reached.

How did you hear about Pleasant Hill Goshen Fire and Rescue and our volunteer program?

To assist with verifying previous work experience and/or education, please list other names you have used:

PLEASE READ THE FOLLOWING STATEMENTS AND CAREFULLY REVIEW YOUR ENTIRE APPLICATION MATERIAL BEFORE SIGNING BELOW.

Eligible Employees and/or Volunteers WILL:

- Be 18 years at the time of conditional offer of employment

- Possess a valid state driver’s license and acceptable driving record by time of conditional offer of employment.

- Have no criminal conviction that would prevent certification from the Oregon Department of Public Safety Standards and Training (DPSST). Mandatory Conviction information can be found at http://www.oregon.gov/dpsst/PS/docs/PSDisquals.2014.pdf

- Successfully pass oral interview process

- Successfully pass an in-depth background investigation

- Successfully complete a medical and drug screening test

- Successfully complete District orientation training

- Successfully complete District approved academy

- Successfully complete physical agility test

Certification of Understanding:

- I also authorize the Pleasant Hill Goshen Fire & Rescue to make all necessary and appropriate investigations allowable by law to verify the information concerning my employment.

- I understand that in consideration for my employment: I agree to comply with all federal, state and local laws, as well as District policies, procedures, rules/regulations, and guidelines, which may be changed from time to time.

- I understand that despite its legality in Oregon the Pleasant Hill Goshen Fire & Rescue maintains a policy in adherence with Federal Guidelines for Marijuana use. I agree to comply with this policy and submit to a drug screen from time to time should one be requested.

- By signing this application, I certify that all statements made on this form are true and complete to the best of my knowledge. I understand that, any omission, misstatement, or falsification may be cause for rejection of this application and/or discharge from Pleasant Hill Goshen Fire & Rescue.

Full Name*

Signature*

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Today's Date*