Application

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SPECIAL SKILLS, QUALIFICATIONS and CONSIDERATIONS

Education

Certificates

References

List three non-relatives who are familiar with your qualifications, actual work history and abilities.

Medical History

Employment History

List three of your last jobs in order starting with your present or last employer.

Supplemental Questions

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List your experience with a ambulance transporting agency

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Additional Information

In Case of an Emergency 

Please list at least one emergency contact

Affidavit

I acknowledge that my employment with the Jefferson Rural Fire Protection District is subject to
compliance with all Policies and Procedures, Standard Operational Guidelines, and the laws of
the State of Oregon. I understand that I may be terminated for any reason at any time.
I expressly waive all provisions of the law prohibiting a physician or hospital from disclosing to
Jefferson Rural Fire Protection District any treatment of information from Marion County, Linn
County, the State of Oregon or other organization, information relative to my past driving
record, criminal record, or other information relative to my position with the Jefferson Rural
Fire Protection District. It is the policy of Jefferson Rural Fire Protection District to verify
background information.

 

I certify that all answers and statements I have made on this application, and supplemental
materials, are true and complete without omission. I understand that any false information will
be grounds for refusal to hire or immediate discharge if I am employed.

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