Snohomish County Fire District No. 21

Application for Employment

Employment Application Online Form

(You must be 18 years of age to apply for employment.)

Today's Date

Full name

Date of birth

Email Address

Address

City / State

Phone

Are you 18 or older? Are you 18 or older? Yes No

Drivers license #

Are you a citizen of the United States

If no, are you authorized to work in the U.S.?

Check each item of documentation you can provide Check each item of documentation you can provide Driver License EMT License Firefighter I Firefighter II Hazmat Operations Certificate Hazmat Awareness Certificate CPAT Card

What areas of the fire service/public service interest you? Such as firefighting, medical services, technical rescue (such as water rescue), supportive functions, or other.

Do you have any activities, commitments, or responsibilities that may prevent you from meeting attendance guidelines?

If yes, please explain:

Where do you see yourself in five years as it relates to your future in the fire service/public service?

Employment History

1st: Phone / Supervisor / Responsibilites / Reason for leaving

May we contact this supervisor for a reference? May we contact this supervisor for a reference? Yes No

List all jobs you have held in the past 5 years. 1st: Company / Address / Job Title

1st: Dates From - To

2nd: Company / Address / Job Title

2nd: Phone / Supervisor / Responsibilites / Reason for leaving

May we contact this supervisor for a reference? May we contact this supervisor for a reference? Yes No

2nd: Dates From - To

3rd: Company / Address / Job Title

3rd: Phone / Supervisor / Responsibilites / Reason for leaving

May we contact this supervisor for a reference? May we contact this supervisor for a reference? Yes No

3rd: Dates From - To

Education / Training

Highschool Name / From - To

Did you graduate? Did you graduate? Yes No

College Name / From - To

Did you graduate? Did you graduate? Yes No

College degree

Other school / From - To

Degree / Training

Did you graduate? Did you graduate? Yes No

Have you passed the General Education Development program (GED) in place of achieving a high school diploma? Have you passed the General Education Development program (GED) in place of achieving a high school diploma? Yes No

Legal Behavior

Have you been fined for a criminal (misdemeanor or felony) offense within the past 7 years?

Have you been arrested for any crime within the past 7 years?

Have you been cited and released for a criminal (misdemeanor or felony) offense within the past 7 years?

Have you ever been sentenced to jail or prison?

Have you had your driver’s license suspended or revoked within the past 7 years?

Have you ever been refused a security clearance of bond?

Understanding of Requirements

In making this application, it is understood that an investigation may be made, whereby, information is obtained through personal interviews with third parties, such as employers, business associates, law enforcement, friends, or others with whom you are acquainted. This inquiry may include information as to your character, general reputation and personal characteristics, whichever may be applicable. I certify that the answers given by me to all questions on this application are true and correct to the best of my knowledge and belief. I understand that is accepted, false statements or omission of facts on this application shall be considered sufficient cause for termination from service. I authorize you to make any reasonable inquiry of my associates, employer, and law enforcement agency to fully investigate my criminal records history. This application is not a job offer or promise of employment from Fire District No. 21. I hereby release the information contained within this application and any supplementary documents to Snohomish County Fire Districts’ No. 21.

APPLICANTS MUST (Check each box to acknowledge requirement and agree to the paragraph above.) APPLICANTS MUST (Check each box to acknowledge requirement and agree to the paragraph above.) Be at least eighteen (18) years of age at time of application Possess a high school diploma or GED equivalency. Have a current Washington State Driver’s License. Sign and complete in-full this application packet.