Application

First Name

Last Name

Middle Name

Current Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Date of Birth

Social Security Number

Oregon Driver License Number

SPECIAL SKILLS, QUALIFICATIONS and CONSIDERATIONS

Summarize special skills and qualifications, volunteer activities, military experience, employment, or other activities related to the job you are seeking.

Education

School or Collage

Course Work

Dates Attended

Certificates

Please list current certifications such as Firefighter, CPR, ACLS, Fire Officer, Instructor. Include expiration dates and attach copies of the certifications with the application

References

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

Name

Occupation

Years known

Phone

Name

Occupation

Years known

Phone

Name

Occupation

Years known

Phone

Medical History

Jefferson Fire District has special physical requirements and may require an applicant to pass a job specific physical agility test. List any medical conditions that the Fire District should be aware of.

Employment History

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

Employer

Supervisor's Name

Position at the Company

Employer's Address

Start Date

End Date

Reason for leaving

Duties and Responsibilities

Employer

Supervisor's Name

Position at the Company

Employer's Address

Start Date

End Date

Reason for leaving

Duties and Responsibilities

Employer

Supervisor's Name

Position at the Company

Employer's Address

Start Date

End Date

Reason for leaving

Duties and Responsibilities

Supplemental Questions

Fluent in

List Violation

List other departments

List your experience with a ambulance transporting agency

Start Date

End Date

Agency

Start Date

End Date

Agency

Start Date

End Date

Agency

If no, Explain

If yes, Explain

Completed when

Briefly explain your interest in Jefferson Fire District.

Additional Information

Please list any additional information you feel would be important for Jefferson Fire District to know about you.

In Case of an Emergency

Please list at least one emergency contact

Name

Relationship

Phone #

Name

Relationship

Phone #

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.

Your Signature

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Jefferson Fire District

Application

SPECIAL SKILLS, QUALIFICATIONS and CONSIDERATIONS

Education

Certificates

References

Medical History

Employment History

Supplemental Questions

Additional Information

In Case of an Emergency

Affidavit

BUSINESS HOURS

ADDRESS

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