2022 Plain Township Fire Department Lateral Transfer Employment Application

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* 1. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Are You 18 Years or Older?

Yes

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* 3. Employment Position Desired

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* 4. Date you can start?

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* 5. Current hourly wage.

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* 6. Are you employed now?

Yes

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* 7. May we contact your current employer?

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* 8. Have you ever applied to the Plain Township Fire Department before? If so, when?

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* 9. Where did you see this job posted?

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* 10. Are you a U.S. Citizen?

Yes

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* 11. US Military or Naval Service? Rank?

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* 12. Present Membership in National Guard or Reserves?

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* 13. Current Employer

Name of Employer

Date of Employment

Salary

Position

Start Date

End Date

Reason for Leaving

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* 14. Former Employer

Name of Employer

Date of Employment

Salary

Position

Start Date

End Date

Reason for Leaving

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* 15. Former Employer

Name of Employer

Date of Employment

Salary

Position

Start Date

End Date

Reason for Leaving

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* 16. List three references. Use questions 16, 17 and 18 to enter references.

Name

Address

Business

Years Acquainted

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* 17. References

Name

Address

Business

Years Acquainted

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* 18. References

Name

Address

Business

Years Acquainted

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* 19. This position requires graduation from high school or equivalent. Do you possess a high school diploma or equivalency (GED)?

Yes

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* 20. High School Attended

Name of High School:

Address:

Number of Years Attended:

Graduation Date:

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* 21. College Attended

Name of College:

Address:

Number of Years Attended:

Graduation Date:

Major:

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* 22. List additional education such as trade school or business school.

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* 23. This position requires possession of an appropriate valid State of Ohio driver's license on the date of application and maintenance thereafter. Do you possess a current valid driver's license?

Yes

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* 24. Do you have three (3) or more years of experience as a fulltime Firefighter, and one (1) or more years as a certified Paramedic?

Yes

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* 25. NIMS Courses: check the courses you have completed.

IS-100

IS-200

IS-700

IS-800

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* 26. Do you possess any of the following certifications? If so, list the expiration date.

OH Firefighter II Certification

HazMat Awareness Certification

State of Ohio Paramedic Certification

National Registry Paramedic Certification

HazMat Operations Certification

HazMat Tech

Rescue Tech

Fire Inspector

Fire Service Instructor

EMS Instructor

Other

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* 27. Do you possess a current valid American Heart Association CPR certification (BLS certification)? If yes, list the date of expiration. If not, state not applicable.

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* 28. Do you possess a current valid American Heart Association Advanced Cardiac Life Suppor (ACLS) certification? If yes, list the date of expiration. If not, state not applicable.

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* 29. Do you possess a current valid American Heart Association Pediatric Advanced Life Support (PALS) certification? If yes, list the date of expiration. If not, state not applicable.

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* 30. Do you possess a current certification for Basic Trauma Life Support (BTLS) or Pre-Hospital Trauma Life Support (PHTLS) certification? If yes, list the date of expiration. If not, state not applicable.

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* 31. List the last two years of time off request including: Sick Leave, Vacation, Comp. Time, and Trades. For example, Sick Leave 240 hours, Vacation 80 hours.

Sick Leave

Vacation

Comp Time

Trades

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* 32. I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.

Electronic signature required. I agree that by entering my name in the text box this is my legal signature.

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