APPLICATION FOR EMPLOYMENT

Firefighter/Emergency Medical Technician

for the City of Bangor, Maine

Applicants are considered for all positions without regard to race,

color, religion, sex, national origin, age, marital or veteran status or the presence of a non-job-related medical condition or handicap.

The City of Bangor is an equal opportunity employer

.

Date of Application:______________________

Name:______________________________________________________________________________________________________

LAST FIRST MIDDLE

Address:____________________________________________________________________________________________________

NUMBER STREET CITY/TOWN STATE ZIP CODE

Telephone: (_____)________________________

Are you under 18 years of age? YES NO

Have you ever filed an application with Bangor? YES NO

Are you currently employed? YES NO

May we contact your present employer? YES NO

Are you prevented from lawfully becoming employed

in this country because of Visa or Immigration status? YES NO

Proof of citizenship or immigration status will be required upon employment

On what date would you be available for work? _________________

Do you have a high school diploma or equivalency certificate? YES NO

Do you have a current driver’s license? YES NO

Were you ever convicted by a court of an offense other than a traffic violation? YES NO

If yes, briefly describe the offense: _______________________________________________________________________

Do you have the physical and mental abilities to do the job for which you have

applied, with or without a reasonable accommodation? YES NO

List any relatives presently employed by the City of Bangor:__________________________________________________________

Please note the relative’s name and relationship. Relatives include spouses, parents, children, brothers, sisters, mother-in-laws, father-in-laws, brother-in-laws, sister-in-laws, son-in-laws, daughter-in-laws, grandparents, grandchildren, step-parents, step-children, nephews, nieces, aunts, uncles, half-brothers, half-sisters, and first cousins.

EDUCATION:

Number of

Name and Address Course of Study Years Diploma/Degree

of School Completed

High School

Undergraduate

College

Graduate/

Professional

Other (Please Specify)

FIRE FIGHTING EXPERIENCE:

Previous fire fighting training (include copies of certificates and/or diplomas):

_____ Fire Fighter I ____ Fire Fighter II _____ Fire Fighter III

_____ Fire Science Certificate ____ Fire Science Degree

Please describe your experience as a fire fighter (i.e. number of years as a fire fighter, which fire department, etc.):

Describe any specialized training or skills related to your experience as a fire fighter (include copies of certificates and/or diplomas):

EMERGENCY MEDICAL SERVICES EXPERIENCE:

Current EMS license level (Please include copy of current license):

_____ Basic

______ Intermediate

______ Paramedic

______ Other (Please specify) _____________________________________________________________________________

Please describe your experience with the Emergency Medical Services (i.e. number of years in EMS, which rescue squad or fire department):

______________________________________________________________________________________________________

Describe any specialized training or skills related to your experience in EMS (include copies of certificates and/or diplomas):

_____________________________________________________________________________________________________

Please state any additional information in regards to your fire fighting or EMS experiences that you feel may be helpful to us in considering your application:

_____________________________________________________________________________________________________

EMPLOYMENT EXPERIENCE:

Start with your present or last employer. Include any job-related military service assignments and volunteer activities.

EMPLOYER: DATES EMPLOYED:

ADDRESS HOURLY PAY/SALARY: Starting: Final:

TELEPHONE NUMBER: JOB DUTIES: (Continue below)

JOB TITLE:

SUPERVISOR:

REASON FOR LEAVING:

EMPLOYER: DATES EMPLOYED:

ADDRESS HOURLY PAY/SALARY: Starting: Final:

TELEPHONE NUMBER: JOB DUTIES: (Continue below)

JOB TITLE:

SUPERVISOR:

REASON FOR LEAVING:

EMPLOYER: DATES EMPLOYED:

ADDRESS: HOURLY PAY/SALARY: Starting: Final:

TELEPHONE NUMBER: JOB DUTIES: (Continue below)

JOB TITLE:

SUPERVISOR:

REASON FOR LEAVING:

PERSONAL/PROFESSIONAL REFERENCES:

NAME PHONE NUMBER

ADDRESS

NAME PHONE NUMBER

ADDRESS

NAME PHONE NUMBER

ADDRESS

APPLICANT’S STATEMENT:

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

____________________________________________________ ________________________________

APPLICANT’S SIGNATURE DATE

Firefighterapplication.doc