Highlands County Fire Services

Text Box: _____ Active

_____ Support
Fire Dept. Name: Lorida

Fire Dept. Name: Lorida

Volunteer Firefighter Application

Revised 10.8.08

We consider applications for all positions without regard to race, color, religion, sex, national origin, age, marital status, the presence of a non-duty related medical condition or handicap, or any other legally protected status. The information contained in this application form is required by law and / or the Highlands County Board of County Commissioners Personnel Rules and Regulations in order for you to be evaluated for acceptance. Completion of each item is voluntary, but incomplete answers may reduce your chance for volunteer selection. This document will become a permanent part of your personnel file if accepted.

P l e a s e P r i n t or T y p e

Last Name: _______________________ First Name: _____________________ MI: ____

Current Address: _____________________________ City: _______________ Zip: ________

Phone: ( )___________________ Hm ( )___________________ Wk ( )___________________Other

Previous Address: __________________________ City / State: ________________ Zip: ____________

Social Security #: _______________________ Driver’s License #: ________________________ Class: _______

Emergency Contact: _____________________________________ Relationship: _________________________

Address: __________________________ City / State: ________________________ Phone: ( )_________________

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

Employment History

Current: _______________________________________ Position: _____________________ How Long: _______

Address: ____________________________________ Supervisor: ______________________ Phone: _______________

Previous: _____________________________________ Position: ____________________ How Long: ________

Address: ____________________________________ Supervisor: ____________________ Phone: _______________

Previous: _____________________________________ Position: ____________________ How Long: _______

Address: ____________________________________ Supervisor: ____________________ Phone: _______________

List two (2) personal references that you have known for at least three (3) years

(1) Name: _____________________________________________ Relationship: ________________________

Address: _______________________________________ Phone: ( ) _________________________

(2) Name: _____________________________________________ Relationship: ________________________

Address: _______________________________________ Phone: ( )_________________________

(3) Name: ____________________________________________ Relationship: ________________________

Address: ______________________________________ Phone: ( )_________________________

Military Service

Branch of Service: _________________________________ Type of Discharge: __________________________

Dates of Service: ___________________________________ *Attach copy of DD214*

Education

Circle the Highest Level of Education Completed: Grade School High School College / University

1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4

Name of High School Attended: _________________________________ City / State: __________________

College / University: ___________________________________________ City / State: __________________

Criminal History

Have you ever been arrested, charged with, or convicted of violating any laws other than minor traffic laws? If yes, give details. _______________________________________________________________________________________________________

Please list all traffic charges / citations received in the past five (5) years. _______________________________________________________________________________________________________

Has your driver’s license ever been suspended or revoked? If yes, please explain. _______________________________________________________________________________________________________

Related Experience

Have you ever been a part of any other fire department or public safety agency? If yes, please explain. _______________________________________________________________________________________________________

List any certificates or licenses you possess related to public safety. Please include dates of issuance and copies.

_______________________________________________________________________________________________________

List and describe any training you have that would benefit you as a member of a fire department. _______________________________________________________________________________________________________

Briefly state why you want to become a member of a fire department. _______________________________________________________________________________________________________

Personal Vehicle Information

Tag #: ______________ Year: _________ Make / Model: ____________________ Color: _______

I certify that I have liability insurance on my privately owned vehicle and agree to maintain liability coverage. ________

(Please Initial)

Certification

I hereby certify that I am at least 18 years of age. I understand by my signature below that falsification of any part of this application is cause for immediate dismissal whenever discovered and do certify that all statements are true and correct.

I also authorize the making of lawful inquiries regarding both my past and present employment and hereby release those supplying information from all liability. Under Florida’s Sunshine Law, applications for employment with a public agency, such as Highlands County, are subject to public disclosure.

DRUG FREE WORKPLACE POLICY: Highlands County is a Drug Free Workplace in accordance with FS 112. Applicants and employees may be required to submit to drug testing at any time for pre-screening, reasonable suspicion, post accident, return to duty, and follow-up on routine fitness for duty. Additionally, drug and alcohol testing of employees holding a commercial driver’s license is conducted per Federal law and regulation 49 CRF, Part 382.103/107.

_________________ ___________________________ ________________________

Date Signature of Applicant Signature of Witness

Personal Inquiry Waiver

Name: _____________________________ DOB: _________________ SS#: __________________

I respectfully request and authorize you to furnish the Highlands County Division of Fire Services any and all information that you may have concerning my work record, criminal history, school records, military records, and reputation. Please include any and all information of a confidential or privileged nature and photostats of same if requested. This information is to be used by the Highlands County Division of Fire Services in determining my qualifications and fitness for participation as a volunteer firefighter in Highlands County, Florida.

I hereby release you, your organization, and others from any liability or damage which may result from furnishing the information requested.

Signature of Applicant: _____________________________ Date: _____________________

Address: _______________________________________ City / State / Zip: _________________________

Affidavit

State of Florida, County of Highlands

The foregoing instrument was acknowledge by me this __________ day of _____________, 200___ by this

applicant who is _________ personally known to me or __________ who has provided _____________________

______________________ as identification.

_______________________________________ ___________________________________

Signature of Person Taking Acknowledgement Printed Name of Acknowledger