Part-Time Employment Application

Application Type

Type of Applicant* Firefighter / EMT
Firefighter / Paramedic

Hospital Affiliation

PSID Number*

Applicant Information

First Name*

M.I.*

Last Name*

Street Address*

City*

State*

Zip*

Home Phone

Cell Phone*

Email Address*

Gender Male
Female

Date of Birth*

Social Security Number

Driver's License Number*

Additional Information

Do you have a fear of confined spaces?* Yes No

Do you fear heights or darkness?* Yes No

Have you ever been convicted of a felony?* Yes No

Have you ever worked in the fire service?* Yes No

If so, where?

Education

High School

High Shool

Address

From

To

Did you graduate? Yes No

College

Address

From

To

Did you graduate? Yes No

Other

Address

From

To

Did you graduate? Yes No

References

Reference #1

Full Name

Company

Phone

Reference #2

Full Name

Company

Phone

Reference #3

Full Name

Company

Phone

Previous Employment

Previous Employment #1

Company

Job Title

Phone

Address

Supervisor

Starting Salary

Ending Salary

Responsibilities

To

From

Reason For Leaving

May we contact your previous employer? Yes No

Previous Employment #2

Company

Job Title

Phone

Address

Supervisor

Starting Salary

Ending Salary

Responsibilities

To

From

Reason For Leaving

May we contact your previous employer? Yes No

Previous Employment #3

Company

Job Title

Phone

Address

Supervisor

Starting Salary

Ending Salary

Responsibilities

To

From

Reason For Leaving

May we contact your previous employer? Yes No

Military Service

Branch

Rank at Discharge

From

To

Type of Discharge

Document Uploads

When you click on the folder below you will be able to upload your documents. Be sue to include any applicable certifications, and any additional documents you wish to add to your application.

Fire/EMS Certifications

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If my application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Applicant Signature*

Security