APPLICANT INFORMATION Last Name * First Name * M.I. Street Address * Apartment/Unit # City * State * ZIP * Phone Number * Email Address * Date Available To Start * Position Applied For * Can you furnish proof you are eligible to work in the United States? * Yes No Do you have a valid Illinois Driver’s License? * Yes No Have you ever worked for this department? * Yes No Have you ever been convicted of a felony? * Yes No Do you consent to a background check? * Yes No Please explain when you worked at this department, and why you left. * Please Explain * EDUCATION Did you graduate High School? * Yes No Degree * Did you graduate College? * Yes No Degree REFERENCES Please list three Professional references. Full Name * Phone Number * Full Name * Phone Number * Full Name * Phone Number * PREVIOUS EMPLOYMENT Company * Phone Number * Address * Supervisor * Job Title * Starting Salary * Ending Salary * Worked From * Worked Till * Reason for leaving * Company Phone Number Address Supervisor Job Title Starting Salary Ending Salary Worked From Worked Till Reason for leaving Company Phone Number Address Supervisor Job Title Starting Salary Ending Salary Worked From Worked Till Reason For Leaving FIREFIGHTER / EMS CERTIFICATION OR LICENSE COMPLETE ALL THAT ARE APPLICABLE Illinois Certified/Licensed O.S.F.M. Basic Operations FF O.S.F.M. Basic Operations FFII O.S.F.M. Basic Operations FFIII I.D.P.H. EMT Basic I.D.P.H. EMT Paramedic Any other applicable certifications Where did you earn your FF certificate? When did you earn your FF certificate? Where did you earn your FFII certificate? When did you earn your FFII certificate? Where did you earn your FFIII certificate? When did you earn your FFIII certificate? Where did you earn your I.D.P.H. EMT Basic License? When did you earn your I.D.P.H. EMT Basic License? Where did you earn your I.D.P.H. EMT Paramedic License? When did you earn your I.D.P.H. EMT Paramedic License? Other License/Certificates (Please list where and when you received your License/Certificates) SPECIAL SKILLS AND INTERESTS Please Explain Your Skills And Interests MILITARY SERVICE Branch Date Served From Date Served Till AFFIDAVIT PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all of the information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employer and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such person and organizations that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physician examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre-employment drug screen as a condition of employment. If required. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINATE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERNINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. * I have read, understand, and consent to these statements. reCAPTCHA Submit Δ
