Application
Position
Applying for:
{ Employment { Volunteer { Observer
NAME:
__________________________________________________ DOB: ________________________
HOME
ADDRESS: ____________________________________________________________________________
CITY: ___________________________________ STATE: _________________ ZIP CODE: _______-______
SOCIAL
SECURITY NUMBER: __________-_________-__________
HOME
PHONE #: (____) _________-_________ ALTERNATE PHONE #: (____)
______-________
DRIVER’S
LICENSE #: __________________________ STATE: ________________ EXPIRES:
_____________
HAS YOUR
DRIVER’S LICENSE EVER BEEN SUSPENDED OR REVOKED? YES / NO
IF YES,
EXPLAIN: _____________________________________________________________________
HAVE YOU EVER
BEEN ARRESTED AS AN ADULT? YES / NO
IF YES,
EXPLAIN: ______________________________________________________________________
Please
list three references (non-employer):
NAME ADDRESS PHONE
1.
__________________________________________________________________________________
__________________________________________________________________________________
2.
__________________________________________________________________________________
__________________________________________________________________________________
3.
__________________________________________________________________________________
__________________________________________________________________________________
IN CASE OF EMERGENCY WHO
SHOULD BE CONTACTED?
NAME:
________________________ PHONE#: (____) _____-________
Do
you or will you have transportation to work? NO YES
Do
you have any physical limitations that would interfere with your job duties or
require special equipment to be provided?
(If yes please explain) NO YES
________________________________________
PLEASE LIST PRIOR EMPLOYMENT STARTING WITH MOST RECENT EMPLOYMENT FIRST. (Use a separate sheet of paper if more space needed)
COMPANY NAME:
______________________________________ POSITION: __________________
SUPERVISOR:
__________________________ PHONE#: (____) ______-_______
COMPANY ADDRESS:
_____________________________________________________________
START DATE: _ _ /_ _ / _ _ _
_ END DATE: _ _ / _ _ / _ _ _ _
START PAY RATE: ___________ END PAY RATE: ___________ (hourly, monthly, biweekly)
DUTIES: _____________________________________________________________________________
COMPANY NAME:
______________________________________ POSITION: __________________
SUPERVISOR:
__________________________ PHONE#: (____) ______-_______
COMPANY ADDRESS:
_____________________________________________________________
START DATE: _ _ /_ _ / _ _ _
_ END DATE: _ _ / _ _ / _ _ _ _
START PAY RATE: ___________ END PAY RATE: ___________ (hourly, monthly, biweekly)
DUTIES: _____________________________________________________________________________
COMPANY NAME:
______________________________________ POSITION: __________________
SUPERVISOR:
__________________________ PHONE#: (____) ______-_______
COMPANY ADDRESS:
_____________________________________________________________
START DATE: _ _ /_ _ / _ _ _
_ END DATE: _ _ / _ _ / _ _ _ _
START PAY RATE: ___________ END PAY RATE: ___________ (hourly, monthly, biweekly)
DUTIES: _____________________________________________________________________________
May
we contact you previous employers? NO YES
LIST
MEMBERSHIPS (CURRENT OR PAST) WITH ANY OTHER FIRE DEPARTMENTS, RESCUE SQUADS,
CLUBS, AND ETC.
______________________________________________________________________________________
***** VOLUNTEER APPLICANTS SIGN THIS SECTION *****
DO YOU HAVE CERTIFICATION IN CPR, EMT, PARAMEDIC, OR OTHER RELATED FIELDS? YES / NO
IF YES, PLEASE SUBMIT COPIES WITH THIS APPLICATION
I, _____________________________________UNDERSTAND THAT ANY FALSIFICATION/FAILURE TO DISCLOSE INFORMATION ON THIS APPLICATION WILL AUTOMATICALLY VOID THIS APPLICATION. I UNDERSTAND THAT BENSALEM RESCUE SQUAD, INC. HAS THE RIGHT TO REJECT ANY AND ALL APPLICATIONS AND THAT I MAY BE TERMINATED FROM MEMBERSHIP WITHOUT REASON AT ANY TIME. I HEARBY GIVE BENSALEM RESCUE SQUAD, INC, THE BENSALEM POLICE DEPARTMENT, OR THE SQUAD’S DESIGNEE PERMISSION TO INVESTIGATE MY BACKGROUD AND ANY INFORMATION DEEMED NECESSARY FOR THE COMPLETION OF THIS APPLICATION.
____________________________________________________________________ __________________________________
SIGNATURE DATE
*** IF UNDER 18 YEARS OF AGE, A PARENT
OR GUARDIAN MUST ALSO SIGN.
____________________________________________________________________ ________________________________
SIGNATURE DATE
______________________________________________________ ________________________________
PRINTED
NAME RELATIONSHIP TO APPLICANT
*** If under 18 a copy of working
papers must be submitted with application.
*****
EMPLOYMENT APPLICANTS SIGN THIS SECTION *****
BENSALEM RESCUE SQAUD, INCORPORATED IS AN EQUAL OPPORTUNITY EMPLOYER. ALL PERSONNEL EMPLOYED AFTER JANUARY 01, 1994 EMPLOYED AT WILL AND MAY BE DISMAYED AT ANY TIME WITHOUT REASON.
I, _________________________________ UNDERSTAND THAT ANY FALSIFICATION ON THIS APPLICATION WILL AUTOMATICALLY VOID THIS APPLICATION. IN THE EVENT I AM HIRED ANY FOUND FALSIFICATION OF THIS DOCUMENT MAY RESULT IN MY IMMEDIATE TERMINATION. I HEREBY GIVE THE BENSALEM RESCUE SQUAD, AND THE BENSALEM POLICE DEPARTMENT, ATLANTIC SECURITY, OR OTHER DESIGNEE OF BENSALEM RESCUE SQUAD, INC. PERMISSION TO INVESTIGATE MY BACKGROUND AND ANY INFORMATION THEY DEEM NECESSARY FOR THE COMPLETION OF THIS APPLICATION.
SIGNED: ____________________________________ DATE: __ __/ __ __/ __ __ __ __
*****
ALL APPLICANTS OVER 18 YEARS OF AGE OR OLDER *****
·
Must submit a certified check or Money Order for
$10.00 made payable to the Commonwealth of Pennsylvania with application
(Observer’s Do Not Have to Submit Fee for Background Investigation) This fee is
non-refundable.
·
Must submit a photo copy of current driver’s
license or photo ID with application
·
Must submit copies of any applicable
certifications with application.
e.g. CPR / EMT / EMT-P / ACLS /
PALS / and etc.