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GORDON COUNTY DEPARTMENT OF FIRE & RESCUE EMPLOYMENT APPLICATION For the Position of Part-time, per Call Firefighter (formerly known as volunteer) ---PAGE BREAK--- 2 APPLICATION FOR PART-TIME, PER-CALL SERVICE Please print legibly using legible ink! Gordon County depends heavily on part-time, per call members who live within 5 road miles of a fire station and are available for response within that area to supplement the response of the career members of the department. Please take the time to read this application thoroughly, paying close attention to detail and providing all requested information. The job of a firefighter is very demanding. All candidates will be required to complete Gordon Co. Fire Rescue’s Candidate Physical Ability Test (CPAT). A practice session will be scheduled. Candidates are not required to attend the practice session; however, all candidates will be required to complete the (CPAT). PERSONAL INFORMATION Name: SSN (Required): (Last) (First) (Middle Initial) List any Alias Names used (i.e. maiden names, nicknames, and etc. Present Street Address: (City) (State) (Zip Code) Have you reached your 18 th birthday? □ Yes □ No Home Phone # Business Phone # Cellular Phone # Email address (Please provide a valid email address; it will be used to communicate with you): Person to contact in case of emergency: Telephone # Are you willing to respond to calls for service and work extended hours, nights, weekends, holidays, etc.? □ Yes □ No Are you willing to attend meetings and mandatory training as required? □ Yes □ No EDUCATION Are you a high school graduate of an accredited high school? □ Yes □ No *If yes, please list below the high school attended and provide a copy of high school diploma with this application. Did you graduate from a recognized home school program? □ Yes □ No * If yes, please provide a copy of your GED from the Department of Technical and Adult Education. If not a high school graduate, do you have a GED from an accredited institution? □ Yes □ No Provide a certified copy with this application. School Name and Location Major Course of Study Grade Completed Type of Diploma/Degree High School 9 10 11 12 Business/Technical School 1 2 3 4 College 1 2 3 4 Graduate School 1 2 3 4 Do you have any prior military service? □ Yes □ No If yes, how many years? What MOS, major job responsibility, or certifications did you obtain during your military service? ---PAGE BREAK--- 3 GENERAL INFORMATION Have you ever been employed by Gordon County? □ Yes □ No If yes, when? What department or office? Are you related to anyone currently employed by Gordon County? □ Yes □ No Relative’s Name Relationship Department/Office How did you learn of this position? Are you a citizen of the United States? □ Yes □ No Have you ever been convicted or plead guilty or Nolo to a felony or misdemeanor, other than a minor traffic violation? □ Yes □ No If yes, when? Where? For what? Are you currently a member of any of the active military branches? □ Yes □ No If yes, what branch? Please list all of your previous addresses for the last five years, starting with your present address. Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other Address: From: Mo/Yr From: Mo/Yr Did you: □ Rent □ Own □ Other ---PAGE BREAK--- 4 EMPLOYMENT RECORD Describe your work history beginning with your current or most recent job. Include military and/or volunteer experience. Failure to give complete information regarding each job held may result in your disqualification. Complete addresses with zip codes and phone numbers for all employers are necessary. A resume may be attached only as additional information and will not be accepted in lieu of completing this section. Company Name: Street Address City State Zip Code Supervisor’s Name Telephone From: Mo/Yr To: Mo/Yr Position/Job Title Duties Reason for Leaving Company Name: Street Address City State Zip Code Supervisor’s Name Telephone From: Mo/Yr To: Mo/Yr Position/Job Title Duties Reason for Leaving Company Name: Street Address City State Zip Code Supervisor’s Name Telephone From: Mo/Yr To: Mo/Yr Position/Job Title Duties Reason for Leaving Company Name: Street Address City State Zip Code Supervisor’s Name Telephone From: Mo/Yr To: Mo/Yr Position/Job Title Duties Reason for Leaving Company Name: Street Address City State Zip Code Supervisor’s Name Telephone From: Mo/Yr To: Mo/Yr Position/Job Title Duties Reason for Leaving ---PAGE BREAK--- 5 PERSONAL REFERENCES Please list at least four people that are not related to you, or living with you, that you have known for at least 4 years. Name: Street Address City State Zip Code What is this person’s occupation? Best phone # to contact this person Best time to contact this person Name: Street Address City State Zip Code What is this person’s occupation? Best phone # to contact this person Best time to contact this person Name: Street Address City State Zip Code What is this person’s occupation? Best phone # to contact this person Best time to contact this person Name: Street Address City State Zip Code What is this person’s occupation? Best phone # to contact this person Best time to contact this person DRIVING INFORMATION AND HISTORY * IN ACCORDANCE WITH DEPARTMENT POLICY, YOU MUST POSSESS A VALID GEORGIA DRIVER’S LICENSE, HAVE COMPLETED, AS A MINIMUM, THE GEORGIA BASIC FIREFIGHTER MODULE 1 COURSE, AND SUCCESSFULLY COMPLETE THE DEPARTMENT’S DRIVER TRAINING COURSE IN ORDER TO OPERATE DEPARTMENT VEHICLES. Do you have a valid Driver’s License? □ Yes □ No Which State? Driver’s License Number Date of Expiration Have you ever been licensed to drive in another state? □ Yes □ No If yes, indicate which state(s) Have you incurred any traffic charges within the last three years? (Do not include parking tickets) □ Yes □ No If yes, give date(s) and type of charges Please indicate the class driver’s license you have. A B C D E F M (if unsure, look at the bottom left corner of your Driver’s License) (Please provide a copy of your current Driver's License with this application.) Have you been charged or convicted of a DUI in the past five years? □ Yes □ No Have you had more than three moving violations in the past two years? □ Yes □ No ---PAGE BREAK--- 6 SKILLS AND TRAINING Are you a current certified NPQ Firefighter I or II? □ Yes □ No *If yes, submit proof with this application. Are you a current certified firefighter in accordance with the standards established by the Georgia Firefighter Standards & Training Council? □ Yes □ No *If yes, submit proof with this application. Are you a certified National Registry EMT or Paramedic with a current Georgia certification as well? □ Yes □ No *If yes, submit proof with this application. Are you a certified EMT or Paramedic with a current Georgia certification? □ Yes □ No Are you currently, or have you recently been a volunteer firefighter serving in another department with twelve (12) months or more service (served within the last twelve (12) months) that has completed basic firefighter training with the Georgia Fire Academy? □ Yes □ No List any other skills/training you have that you feel would be beneficial to this department. Are you able to perform all the duties listed in the job description? □ Yes □ No If you answered no to the above question, please explain what can be done to provide you with reasonable accommodations? Have you ever been a member of a fire department, rescue squad, or similar organization as a full-time, part-time employee or as a volunteer? □ Yes □ No Name, address and phone of Organization: Date of Service: Position Held: Reason for Leaving: List all related training you completed: DESIRES AND LIMITATIONS In a brief paragraph, state why you wish to be an employee or member of this department; what this department can gain from your participation; and what you expect from this department. Please list any factors that cold restrict your participation in fire fighting; rescue activities; training activities; station maintenance; being away from your family at night; and or being on an incident scene for extended periods of time, both day and night? ---PAGE BREAK--- 7 APPLICANT’S STATEMENT I certify that the information given in this application is true and complete to the best of my knowledge. I understand that this application is not a contract for employment, nor does it guarantee my request for service will be granted. I understand that final authority rest solely with the fire chief. I understand that any untrue statement in this application may result in my dismissal at any time during my affiliation with the Gordon County Department of Fire/Rescue. I authorize the release of high school and college transcripts, information concerning my previous employment, and any information employers may have pertinent to this application and the employment procedures of Gordon County. I hereby release all parties from all liability for any damage that may result from requesting, providing, processing, retaining, or releasing any information about me. A photographic copy of this authorization shall be as valid as the original. I understand that any résumé, letters of reference, etc., submitted with the application, become the property of Gordon County, and cannot be returned. The information I have provided on the application is subject to public disclosure under the Georgia Open Records Act. By signing this application, I hereby acknowledge that I understand and agree to all provisions outlined herein. *A Notary Public must witness your signature. Please ensure you sign and date this document in their presence and their signature and seal are affixed below. Signature of Applicant Date Notary Signature My commission expires (Date) STOP! APPLICANT STOP! DO NOT WRITE BELOW THIS LINE Current Driver's License High School Diploma or Equivalent Criminal and Driver's History Consent Form Credit History Consent Form Screen Drug Consent Form Employment/Education Consent Form ---PAGE BREAK--- 8 CONSENT FORM I HEREBY AUTHORIZE GORDON COUNTY OR IT’S AGENT TO RECEIVE ANY CRIMINAL HISTORY RECORD INFORMATION PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY FEDERAL, STATE, OR LOCAL CRIMINAL JUSTICE AGENCY. I HEREBY AUTHORIZE GORDON COUNTY OR IT’S AGENT TO RECEIVE ANY INFORMATION PERTAINING TO MY DRIVING RECORD WHICH MAY BE IN THE FILES OF ANY FEDERAL, STATE, OR LOCAL CRIMINAL JUSTICE AGENCY. FULL NAME PRINTED STREET ADDRESS CITY STATE ZIP SEX RACE DOB DRIVER’S LICENSE NUMBER SOCIAL SECURITY NUMBER SIGNATURE NOTARY SIGNATURE MY COMMISSION EXPIRES ---PAGE BREAK--- 9 CONSENT FORM CREDIT HISTORY REPORTING I hereby authorize Gordon County or any of its agents to receive any and all information that may be in my personal credit history that is necessary to make an employment decision. FULL NAME PRINTED SIGNATURE DATE NOTARY SIGNATURE DATE MY COMMISSION EXPIRES ---PAGE BREAK--- 10 CONSENT FORM I hereby consent to submit to urinalysis and/or other tests as shall be determined by Gordon County in the selection process of applicants for employment, for the purpose of determining the drug content thereof. I agree that Calhoun Urgent Care, Gordon County Health Department, or Immediate Care Clinic, may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the county or their designee for analysis. I further agree to and hereby authorize the release of the results of said test to Gordon County. I understand that it is the current use of illegal drugs that prohibits me from being employed at Gordon County. I further agree to hold harmless the company and its agents (including the above named physician or clinic) from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection with Gordon County’s consideration of may application. I further agree that a reproduced copy of the pre-employment consent and release form shall have the same force and effect as the original. I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone. Applicant: Print Name SS# Applicant: Signature Date: Witness Printed Name: Witness Signature: ---PAGE BREAK--- 11 CONSENT FORM EMPLOYMENT VERIFICATION AND EDUCATION I HEREBY AUTHORIZE GORDON COUNTY OR IT’S AGENT TO RECEIVE ANY AND ALL INFORMATION THAT MAY BE NECESSARY TO ARRIVE AT AN EMPLOYMENT DECISION. THIS INCLUDES INFORMATION REGARDING MY WORK PERFORMANCE AND EDUCATION, INCLUDING ATTENDANCE/GRADUATION DATES, GPA, AND TRANSCRIPTS. Name Printed Signature Date NOTARY SIGNATURE MY COMMISSION EXPIRES