La Porte City Fire & Rescue Department Application

202 Main Street
La Porte City, IA 50651
Phone: (319) 342-3396
Fax: (319) 342-3770

Application for Fire    Ambulance
Availability for calls & training
Days Available Monday    Tuesday    Wednesday    Thursday    Friday    Saturday    Sunday
Hours Available

 

*Please complete ALL information requested

Name Address

City/State/Zip
Home Phone
 Mobile Phone
 Email Address
 Social Security Number
Are you age 18 or older?   Yes    No Are you currently employed?   Yes    No
May we contact your current employer?   Yes    No
If 'No', why not?
Are you legally eligible to work in the U.S.? (*If offered employment, eligibility documentation will be required.)   Yes    No
Do you have any felony or misdemeanor convictions other than minor traffic violations?   Yes    No
If 'Yes', please indicate the type of conviction, the county and state where the conviction occurred, and the year.

*A conviction will not necessarily disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.
EDUCATION INFORMATION
HIGH SCHOOL COLLEGE
(years completed)		 GRADUATE/PROFESSIONAL
(years completed)		 MILITARY/TRADE
Diploma    GED
Name of High School
 1    2    3    4
Degree Received		 1    2    3    4
Degree Received
List all Education Institutions attended after high school
 Describe any specialized training, apprenticeships, or skills you have received
Indicate all degrees received and/or areas of study
EMPLOYMENT HISTORY
Current (or most recent) Employer
 Address
Employment Dates
 Job Title
 Manager/Supervisor
 Hours/Week
Work Performed
Reason for Leaving
 
Employer
 Address
Employment Dates
 Job Title
 Manager/Supervisor
 Hours/Week
Work Performed
Reason for Leaving
 
Employer
 Address
Employment Dates
 Job Title
 Manager/Supervisor
 Hours/Week
Work Performed
Reason for Leaving
 
Employer
 Address
Employment Dates
 Job Title
 Manager/Supervisor
 Hours/Week
Work Performed
Reason for Leaving
 
Please provide any previous name(s) under which educational or employment records may be found and the year(s) used
 
REFERENCES
List the name, address and telephone number of three work references who are not related to you.
1.)
2.)
3.)

Authorization and Release

By entering my name and information below, I certify that the answers given herin are true and complete to the best of my knowledge. I have not knowingly withheld any fact of circumstance that would, if disclosed, affect my application unfavorably. I understand that any material omission, misrepresentation, or false information given in my application, on my resume, or in my interview(s) may result in my not being considered for a volunteer position with La Porte City Fire/Rescue; and if not discovered by the City until after my accepting a position, may result in immediate termination.

I authorize you to communicate with persons listed as references, former employers, and any others whom you deem necessary. I further authorize any previous employer, educational institution, or government agency to give to any authorized representative of the City of La Porte City, Iowa, any information which they may have bearing upon my present or previous employment, criminal record, motor vehicle record, and/or such other record as may be deemed necessary to determine my fitness for the position. I agree to release from all liability all persons and organizations supplying such information and I also release the City of La Porte City and its representatives for seeking, gathering, and using such information to make a decision.

I understand that completion of this Application does not guarantee that I will be offered a position with La Porte City Fire/Rescue. If an offer is extended to me and I accept it, I understand that I am required to abide by all applicable policies, rules and regulations of the City of La Porte City. I also agree to engage in no outside activity which would involve a material conflict of interest with the City, or which could reflect adversely on the City. If the position for which I am applying requires it, I understand that I may be required to pass a job-related physical examination and/or controlled substances screening. If required, I agree to submit a controlled substances screening and physical examination by the City's designated medial provider. I also understand that a pre-employment background check will be conducted by the La Porte City Police Department.

 

Signature Date
Driver's License Number
Issued by Expires
Commercial Driver's License?   Yes    No Class
Types of endorsements and/or restrictions

 

Additional Information (Please use the form field below to provide any additional information you feel is necessary.)