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2. Date:*
   Date:
4. First Name, Middle I
5. Last Name
7. Street Address
9. City
10. State
11. Zip Code
13. Email Address
15. Phone Number
16. Do You Have Any Experience in the Fire Service/EMS:

    Yes or No- If yes Please list Your Previous Three Agencies

18. Are you a citizen of the United States?

    1. Yes
    2. No
19. If no, are you authorized to work in the U.S.?

    1. Yes
    2. No
21. Are you Currently Certified in CPR/ AED?

    1. Yes
    2. No
22. CPR Card Expiration Date:
26. Convicted of felony?*

    1. Yes
    2. No

    If yes, please explain.

27. Explanation
29. High School
30. Did you graduate?

    1. Yes
    2. No
32. Additional Education--Please list
34. List Any Organizations, Clubs, Or Trade Associations in Which You Are or Have Been a Member?*
35. Your Current Highest Level of EMS/Medical Licensure?
37. What Fire Service Certifications Do You Hold?

    Check all that apply:

    ( )Hazmat Awareness,  ( ) Hazmat Operations

    ( ) Hazmat Technician, ( ) Firefighter I

    ( )Firefighter II, ( ) ARFF Firefighter

    ( ) Driver/Operator, ( ) Driver/Operator Aerial

    ( ) Driver/ Operator ARFF, ( ) Instructor I

    ( ) Instructor II, ( ) Structure Collapse Rescue Tech

    ( ) Officer I, ( ) Officer II, ( ) InspectorI

    
    

39. Do You Possess A Current National Registration with the (NREMT)?
41. What NIMS/ICS Classes Have You Taken & Passed?*

    Check all that apply:

    ( ) IS-100/ ICS-100 , ( ) IS-200 / ICS-200

    ( ) IS-700 / ICS-700, ( ) IS-800/ ICS- 800

    ( ) IS-300/ ICS- 300, ( ) IS-400 / ICS- 400

43. Please List Any Other Fire Service/ EMS Training Classes You have Taken and Passed?
45. Company Phone Number
49. Previous Employer
50. Job Title/Position
52. Address:
54. Starting/Ending Date
56. Responsibilities
58. Reason for Leaving
60. May we contact your previous supervisor for a reference?

    1. Yes
    2. No
62. Previous Employer
63. Job Title/Position
65. Address:
67. Starting/Ending Date
69. Responsibilities
71. Reason for Leaving
73. May we contact your previous supervisor for a reference?

    1. Yes
    2. No
75. Previous Employer
76. Job Title/Position
78. Address:
80. Starting/Ending Date
82. Responsibilities
84. Reason for Leaving
86. May we contact your previous supervisor for a reference?

    1. Yes
    2. No
88. Disclaimer

    I authorize the City of Girard to conduct a background check/ driver's license check through the Kansas Department of Revenue, Divisions of Vehicles.

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

    If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

90. Signature
91. Date*
    Date
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field