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NOTE TO APPLICANT 1. Applicant must LIVE IN OCONEE COUNTY. 2. Applicant must attach an enlarged copy of driver’s license to application. 3. Applicant must attach a copy of high school diploma or GED. 4. Applicant must be 18 years old to be officially on Oconee Fire - Rescue. We will review 17 year old applicants. 5. Application must be returned to the Fire Rescue Office by Applicant. 6. Applicant must attach a color photo to application or let office personnel take picture when returning application. Pursuant to Title II ADA and Section 504 of the Rehabilitation Act of 1973, as amended, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance or under any program or activity conducted by Oconee County, Georgia. Additionally, pursuant to Title VI of the Civil Rights Act of 1964 and the Civil Rights Restoration Act of 1987, no person shall on the grounds of race, color, or national origin be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity conducted by Oconee County, Georgia. ---PAGE BREAK--- OFFICE USE ONLY: REC’D IN OFFICE REQUIRED FORMS [ ] NO [ ] YES OCONEE COUNTY FIRE - RESCUE APPLICATION (CHECK WHAT YOU ARE MAKING APPLICATION FOR) [ ] FIRE [ ] MEDICAL Please print using blue or black ink only FULL NAME: (Last) (First) (Middle) Date of Birth: Social Security No.: Address: Mailing Address: Home Phone Number: Mobile Phone Number: E-Mail Address: Briefly explain why you are applying for a position in Oconee County’s Fire-Rescue Service: How did you learn about volunteering with Oconee County Fire-Rescue: Driver’s License Number: Class: Status – Valid or Not Valid: If Driver’s License suspended, explain: Driver’s License restrictions (if any): Employed by: Work Address: Work Phone Number: Can you be called at work [ ] No [ ] Yes Page 1 of 9 ---PAGE BREAK--- Emergency Information Is there any pertinent medical history or information that Oconee County Fire-Rescue should know about: [ ] No [ ] Yes If yes, explain: Blood Type: List any allergies: Do you carry medication(s): [ ] No [ ] Yes If yes, name of medication(s) and where kept: Personal Physician’s Name: Phone Number: Hospital of choice: Name of person to contact in case of emergency: Phone Number: Background Information Do you have a High School Diploma [ ] or GED [ ] ? NOTE: You must provide a copy. Have you been convicted of a D.U.I. in the last five years? [ ] No [ ] Yes If yes, give date(s) and disposition(s): Since the age of seventeen (17) have you ever been charged or convicted of any criminal offense? [ ] No [ ] Yes If yes, give date(s) and explanation: Since the age of seventeen (17) have you ever been charged, indicted, or convicted of any type of drug related offense? [ ] No [ ] Yes If yes, give offense, court, and probation officer’s name: Page 2 of 9 ---PAGE BREAK--- Training Information Do you have any previous experience serving with a fire department or rescue unit? [ ] No [ ] Yes Do you hold a valid certification card or completion certificate in any of the following? (Check box) [ ] GFA Approved Firefighter I Location of class: Date Completed: [ ] Red Cross 10 Hr. First Aid or Equivalent Expiration Date: [ ] CPR - American Heart Association/Red Cross Expiration Date: [ ] CPR - American Heart Association/Red Cross Instructor Expiration Date: [ ] GEMA Rescue Specialist Expiration Date: [ ] GEMA 16 Hr. Crash Victim Extrication Location of class: [ ] GEMA 8 Hr. Awareness for Initial Response to Hazardous Materials Incident Location of class: [ ] DOT/DHR Approved First Responder Location of class: Course Hours: [ ] GA DHR Emergency Medical Technician Expiration Date: [ ] GA Composite State Board of Medical Examiner Paramedic License Expiration date: Page 3 of 9 ---PAGE BREAK--- References List Two people not related to you and their address and phone number: The information provided on this application is the truth to the best of my knowledge and belief. I understand that any falsification of information on this application will be grounds for rejection and or termination from Oconee County’s Fire-Rescue. I understand that this application will be used by Oconee County Fire-Rescue to assist in placement of personnel in the Fire Service and/or Rescue Unit and to provide Oconee County with information for insurance purposes. I also agree to and understand that I must meet all training, meeting, and response requirements established by Oconee County Fire-Rescue and that I will be placed on a probationary period. I understand that I can be terminated during said probationary period without cause. Upon completion, this application becomes property of Oconee County Fire-Rescue and will be retained in the confidential personnel files at the Oconee County Fire-Rescue Office. TO PROCESS YOUR APPLICATION THE FOLLOWING MUST BE TURNED IN WITH THE APPLICATION; FAILURE TO DO SO MAY RESULT IN THE APPLICATION PROCESS BEING DELAYED AND YOU MAY MISS THE APPLICATION REVIEW DATE: COMPLETED/LEGIBLE APPLICATION FORM COPY OF A VALID GEORGIA DRIVER’S LICENSE COPY OF HIGH SCHOOL DIPLOMA SIGNED AND WITNESSED DRUG POLICY APPLICANT’S SIGNATURE DATE Page 4 of 9 ---PAGE BREAK--- Drug Test Consent and Information Release Form I understand that one of the components of the Oconee County Drug and Alcohol Policy is a urine test for drugs and/or alcohol as a condition of employment. A positive test will result in: a) Denial of employment; b) Disciplinary Action to include termination of employment. I authorize the testing laboratory to release the results of this drug and alcohol test only to the Oconee County Medical Review Officer or designee, the Oconee County Board of Commissioners and their legal counsel, the applicable Department Head, those Oconee County employees who have a valid need to know, or those involved in any appeal process should it become necessary. I understand that this information will otherwise be kept confidential and will not be released without my written consent or as is otherwise permitted by law. I release the medical personnel and any and all of their employee/owners or representatives from any and all liabilities arising from the release or use of the information derived from or contained in my drug results. During the process of testing a urine specimen for drugs, the specimen is also tested for excessive dilution (excess water in the specimen). In order for the specimen to be a valid specimen, it must not be a dilute specimen. For 6 hours before the test, please do not drink more than 12 ounces of liquid including alcohol or caffeinated beverages (such as sodas, coffee, or tea) or take a diuretic (water pill) unless it is medically necessary. If you take diuretics prescribed by a physician, and it is medically necessary that you take the diuretic on the day of specimen collection, please inform the collector at the time that the specimen is collected. The prescription for the diuretic will need to be verified by the medical review officer if the specimen is dilute. Read, acknowledged and consented to, this day of Applicant’s Name (Please Print) Applicant’s Signature Witness Signature Applicant’s social security number Page 5 of 9 ---PAGE BREAK--- Georgia Driver's History Consent Form O.C.G.A. § 40-S-2(f)(4) authorizes local fire departments and law enforcement agencies access to Georgia driver's history records as part of an application for employment or any current employee for use relative to the performance of official duties with the local fire or law enforcement agency. I hereby authorize the Oconee County Fire Rescue List Name of Law Enforcement Agency/Fire Department To receive a copy of my Georgia Driver's History record as part of my application for employment, or for use relative to the performance of my official duties with the agency. Full Name (print) Address Sex Race Date of Birth Social Security Number Driver’s License Number This authorization is valid for 90 days from the date of signature. Signature Date To be completed by CJIS network operator: Date of Inquiry Time of Inquiry Operator's Initials Date Results Provided Person Results Provided to Georgia Driver's History Consent Form Revised 20200410 Page 6 of 9 ---PAGE BREAK--- Name-Based Criminal History Record Information Consent/Inquiry Form I hereby authorize Oconee County Fire Rescue to conduct an inquiry for Agency/Company the purpose listed below and receive any Georgia and/or national criminal history record information as authorized by state and federal law. Full Name (print) Address Sex Race I Date of Birth I Social Security Number I I This authorization is valid for days from date of signature. I, , give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment. Signature Date Attorney for Individual (Pur E and U Only) Bar Number Date Date of Inquiry: Time of Inquiry: Operator's Initials: Purpose Code Used: (check one) NON-CRIMINAL JUSTICE PURPOSES E - Employment M - Working with Mentally Disabled N - Working with Elderly W - Working with Children P - Public Records (no consent required) PERSONAL REQUEST (INDIVIDUAL OR THEIR ATTORNEY) U - Personal Copy CRIMINAL JUSTICE EMPLOYMENT J - Civilian Criminal Justice Employment (State & Ill Info Received) Z - Sworn Criminal Justice Employment (State & Ill Info Received) The inquiry resulted in the following: (check all that apply) No Criminal Record Available Criminal Record (Attached/Released) No NCIC/GCIC Warrant Possible NCIC/GCIC Warrant (List Wanting Agency Below) Wanting Agency Name: Wanting Agency Telephone: Agency Designee Signature and Title Page 7 of 9 Revised March 2019 ---PAGE BREAK--- I authorize any person(s), firm or organization to furnish Oconee County with any and all information concerning my previous or current employment, education, or any other information, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damage which may result from furnishing such information to Oconee County. I authorize you to request, receive, and verify all information given in this application. Printed Name Signature Date Signed Page 8 of 9 ---PAGE BREAK--- POST OFFER OF EMPLOYMENT MEDICAL INQUIRY Responses to these questions are completely confidential and will be utilized only if necessary to determine if any reasonable accommodation is required for any work you may perform, whether any health condition may pose a direct threat of injury to yourself or others, to assist with treatment of any work-related injury, or for any other lawful purpose. This form does not request, nor should you provide, any information regarding family medical history, the medical condition of any family member, or any genetic information whatsoever. Name: Department: Position: To the best of your knowledge, do you have or have you had any of the following Medical conditions? (For ryes" responses, indicate the nature of injury or illness and name of physician in the remarks section.) Page 9 of 9