Fire Department Application City of Madelia

PERSONAL INFORMATION
Date of Application:
MM slash DD slash YYYY
Name:
First Middle Last
Email*
Present Address:
Street Address City State ZIP Code
Permanent Address:
Street Address City State ZIP Code
Date of Birth:
MM slash DD slash YYYY
Phone Number:
EMPLOYMENT DESIRED
Position(s) Applied For:
Available Start Date:
MM slash DD slash YYYY
Required Salary:
Have you previously filed an application with this agency?
- Yes
- No
If yes, please state the approximate date of your application:
MM slash DD slash YYYY
Have you been previously employed with this agency?
- Yes
- No
If yes, please state the approximate dates of your employment:
Are you currently employed elsewhere?
- Yes
- No
If yes, may we contact this employer?
- Yes
- No
Employer:
Name of Supervisor:
First Last
Phone Number:
Work Availability:
- Full-Time
- Part-Time
- Temporary
List Hours Available:
EDUCATION
High School (Name and Location):
Years Completed:
Diploma/Degree:
College/Trade (Name and Location):
Years Completed:
Diploma/Degree
Other (Name and Location):
Years Completed:
Diploma/Degree
Please list all licenses held relevant to employment
License #1
Type:
Number:
Class:
Exp.Date:
MM slash DD slash YYYY
License #2
Type:
Number:
Class:
Exp.Date:
MM slash DD slash YYYY
License #3
Type:
Number:
Class:
Exp.Date:
MM slash DD slash YYYY
EMPLOYMENT EXPERIENCE
Please list your past three employers, with the present or most recent employer first.
EMPLOYER #1
Employer:
Dates Employed:
Start:
End:
Address:
Street Address City State ZIP Code
Phone Number:
Job Title:
Supervisor's Name:
First Last
Supervisor's Title:
Reason for Leaving:
EMPLOYER #2
Employer:
Dates Employed:
Start:
End:
Address:
Street Address City State ZIP Code
Phone Number:
Job Title:
Supervisor's Name:
First Last
Supervisor's Title:
Reason for Leaving:
EMPLOYER #3
Employer:
Dates Employed:
Start:
End:
Address:
Street Address City State ZIP Code
Phone Number:
Job Title:
Supervisor's Name:
First Last
Supervisor's Title:
Reason for Leaving:
PERSONAL REFERENCES
Reference #1
Name:
First Last
Address:
Street Address City State ZIP Code
Phone Number:
Years Acquainted:
Reference #2
Name:
First Last
Address:
Street Address City State ZIP Code
Phone Number:
Years Acquainted:
Reference #3
Name:
First Last
Address:
Street Address City State ZIP Code
Phone Number:
Years Acquainted:
I authorize investigation of all statements contained in this application for employment as may be necessary to determine eligibility for employment. I certify that answers given herein are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I understand and agree that, if hired, my employment is for no definite period and may be terminated at any time.
- Checking this box serves as my signature.
Date:
MM slash DD slash YYYY
SUPPLEMENTAL APPLICATION FORM
You must complete this form to be considered an applicant for the position of Fireman with the City of Madelia. Please do not list ‘see resume’ as a response.
Name:
First Middle Last
1. Do you have a valid Minnesota driver’s license?
- Yes
- No
2. Do you have any traffic violations in the past five years?
- Yes
- No
3. Do you smoke or use smokeless tobacco?
- Yes
- No
If yes, please indicate cigarettes or smokeless:
4. Do you live within the city limits of Madelia?
- Yes
- No
5. Can you drive a truck with a clutch?
- Yes
- No
6. Can you lift/dead lift 100 lbs?
- Yes
- No
7. Do you have any issues wearing an air pack?
- Yes
- No
8. Can you respond to a fire call at any time?
- Yes
- No
If no, please indicate when you would not be able to respond:
9. Do you have any problems working in a confined space?
- Yes
- No
Informed Consent
General Authorization and Release Pursuant to Minnesota Statutes §13.05, Subd. 4, Minnesota Data Practices Act
I hereby authorize and grant my informed consent to permit the release of data to the police department serving the City of Madelia, Minnesota, and/or its agent and/or representatives, data classified as private which concerns me and that may be in your possession. The data which I authorize to be release consists of private data as define by Minnesota Statutes §13.04, Subd. 12, and has been collected by you as a result of my contacts and associations with you and/or your representatives. The information from which release is authorized includes all data which has been collected, created, received, retained, or disseminated in whatever form which in any way relates to my dealings with you or your agency. I understand that the following types of data are among those pertinent to the review of my employment applications: educational records, military record, employment data (current and former), arrest records, conviction records, professional and personal references, and driver’s license records. I understand that the purpose of permitting the City of Madelia to have access to this information is to determine my suitability for employment.
I understand that any decision to hire me is contingent upon the results of an investigatory report. I further understand that misrepresentation or omission of information will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I hereby release any person who provides information pursuant to this document from any claims or liability by me or on my behalf.
By signing this authorization, I hereby release the Police Department serving the City of Madelia and the Bureau of Criminal Apprehension from any and all liability which otherwise may or does happen as a result of the release of any and all data, regardless of its accuracy. I also release the City of Madelia from any and all liability for its receipt and use of data received pursuant to their consent.
This authorization or a copy of this authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to the expiration, cancel the written authorization by providing written notice to the City or to you of that fact.
Signature Checkbox:*
- Checking this box serves as my signature that I have read and agree to the above statements.
Date*
MM slash DD slash YYYY
Applicant Information
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Applicant Date of Birth*
MM slash DD slash YYYY
Driver’s License Number*
Driver’s License State*
CAPTCHA

(507) 642-3245

Fire Department Application

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

Please list all licenses held relevant to employment

License #1

License #2

License #3

EMPLOYMENT EXPERIENCE

EMPLOYER #1

EMPLOYER #2

EMPLOYER #3

PERSONAL REFERENCES

Reference #1

Reference #2

Reference #3

SUPPLEMENTAL APPLICATION FORM

Informed Consent

Applicant Information