ROSE FIRE COMPANY NO. 1,
NEW FREEDOM BORO, YORK CO., PA
Application for Employment/Membership
Rose Fire Company No. 1, New Freedom Boro, York Co., PA ("Rose Fire Company") considers applications for employment/membership without regard to race, color, national origin, ancestry, religion, sex, age, disability, political belief, military service, citizenship or any other protected class. Rose Fire Company IS A DRUG-FREE WORKPLACE.
I am applying for:
 Full-Time Employment
 Part-Time Employment
 Emergency Responder Membership
 Social Membership
 Junior Emergency Responder Membership
 Junior Membership
Personal Information
FIRST NAME
MIDDLE NAME
LAST NAME
ADDRESS
CITY
STATE
ZIP CODE
EMAIL ADDRESS
PRIMARY TELEPHONE NO.
OTHER PHONE
ARE YOU AT LEAST 18 YEARS OF AGE?
 Yes     No
DATE AVAILABLE TO START:
IF APPLYING FOR JUNIOR MEMBERSHIP, ARE YOU AT LEAST 14 YEARS OF AGE AND LESS THAN 16 YEARS OF AGE?
 Yes     No
IF APPLYING FOR JUNIOR EMERGENCY RESPONDER MEMBERSHIP ARE YOU AT LEAST 16 YEARS OF AGE?
 Yes     No
If you are not at least 18 years of age, a parent or legal guardian must sign this Application (in addition to the Applicant), and, if you are still in high school, you must supply a work certificate.
HOW DID YOU FIND OUT ABOUT ROSE FIRE COMPANY?
DO YOU HAVE ANY RELATIVES OR FRIENDS WORKING/VOLUNTEERING HERE? IF SO, PLEASE LIST:
HAVE YOU EVER WORKED/VOLUNTEERED FOR THIS ORGANIZATION?
 Yes     No
IF SO, DATE(S):
PRIOR POSITION(S) HERE:
REASON(S) FOR LEAVING:
CERTIFICATION INFORMATION

(List only current certifications - photocopies required at interview)
CERTIFICATION
CERTIFICATION
NUMBER
EXPIRATION
DATE?
CERTIFYING
AGENCY
CPR
EMT/PARAMEDIC
NATIONAL REGISTRY
PALS
ACLS
BTLS
EMD
CDL
EVOC/EMS VEHICLE OPERATOR
Other
WORK REQUIREMENTS AND GENERAL INFORMATION
CAN YOU PROVIDE PROOF, IF HIRED, THAT YOU ARE ELIGIBLE TO WORK IN THE U.S.?
 Yes     No
DO YOU HAVE A VALID DRIVER'S LICENSE?
 Yes     No
CLASS
ISSUED BY WHAT STATE?
DRIVER'S LICENSE #
LIST ALL MOVING VIOLATIONS (CONVICTIONS) AND ACCIDENTS AND ANY SUSPENSIONS OR REVOCATIONS OF YOUR LICENSE IN THE LAST FIVE YEARS:
HAVE YOU EVER BEEN CONVICTED, OR PLED GUILTY OR NO CONTEST TO A FELONY OR MISDEMEANOR, INCLUDING A DUI/DWI OR SIMILAR OFFENSE, HAD ANY MOVING VIOLATIONS, OR HAD YOUR LICENSE REVOKED OR SUSPENDED?
 Yes     No
IF SO, EXPLAIN:
A conviction will not necessarily disqualify you from employment.
HAVE YOU EVER BEEN EXCLUDED OR ARE YOU CURRENTLY EXCLUDED FROM PARTICIPATING IN ANY FEDERAL HEALTH PROGRAM SUCH AS MEDICARE OR MEDICAID?
 Yes     No
IF SO, EXPLAIN:
EMPLOYMENT HISTORY
(List your last three employers or volunteer activities, starting with the most recent.)
1 EMPLOYER
JOB TITLE
SUPERVISOR
START DATE
SALARY
JOB DESCRIPTION (INCLUDE DUTIES AND RESPONSIBILITIES):
EMPLOYER'S TELEPHONE #
MAY WE CONTACT?
 Yes     No
REASON FOR LEAVING
2 EMPLOYER
JOB TITLE
SUPERVISOR
START DATE
SALARY
JOB DESCRIPTION (INCLUDE DUTIES AND RESPONSIBILITIES):
EMPLOYER'S TELEPHONE #
MAY WE CONTACT?
 Yes     No
REASON FOR LEAVING
3 EMPLOYER
JOB TITLE
SUPERVISOR
START DATE
SALARY
JOB DESCRIPTION (INCLUDE DUTIES AND RESPONSIBILITIES):
EMPLOYER'S TELEPHONE #
MAY WE CONTACT?
 Yes     No
REASON FOR LEAVING
MILITARY:
BRANCH OF SERVICE
DATE BEGAN
DATE ENDED
RANK & DUTIES
DATE DISCHARGED
LOCATION
EXPLAIN ANY GAPS IN EMPLOYMENT:
PAST EMPLOYMENT:
Have you ever been:
Disciplined or terminated for reckless driving?
 Yes     No
Placed on probation or terminated for excessive absenteeism?
 Yes     No
Disciplined or fired for violation of safety rules?
 Yes     No
Disciplined or fired for assault or fighting?
 Yes     No
Disciplined or fired for harassment?
 Yes     No
Disciplined or fired for patient abuse?
 Yes     No
Disciplined or fired for alcohol or drug related activity at work?
 Yes     No
If you answered yes to any question above, please explain:
EDUCATION AND TRAINING:

HIGH SCHOOL:

NAME
ADDRESS
YEARS COMPLETED
Did you graduate?
 Yes     No
If not, highest grade completed?
Have you received your GED?
 Yes     No

COLLEGE:

NAME
ADDRESS
YEARS COMPLETED
Did you graduate?
 Yes     No
If not, highest year completed?
Degree?
 Yes     No
Major:

OTHER COLLEGE:

NAME
ADDRESS
YEARS COMPLETED
Did you graduate?
 Yes     No
If not, highest year completed?
Degree?
 Yes     No
Major:

TECHNICAL SCHOOL:

NAME
ADDRESS
YEARS COMPLETED
Did you graduate?
 Yes     No
If not, highest year completed?
Certificate?
 Yes     No
License:
Expires:
Expires:

OTHER SCHOOL/TRAINING:

NAME
ADDRESS
YEARS COMPLETED
Did you graduate?
 Yes     No
If not, highest year completed?
Certificate:
 Yes     No
License:
Expires:
Expires:
Other:
EMS/FIRE SERVICE RELATED TRAINING NOT LISTED ABOVE:
EMS/FIRE/PROFESSIONAL AFFILIATIONS (other than listed under prior employment):
Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know when considering your application:
REFERENCES:
List three persons, other than relatives, who have knowledge of your work experience and/or education:
Name
Address
Occupation
Years Known
Telephone Number (including area code)
Name
Address
Occupation
Years Known
Telephone Number (including area code)
Name
Address
Occupation
Years Known
Telephone Number (including area code)
List two personal references that have known you for at least three years outside work:
Name
Address
How they know you
Years Known
Telephone Number (including area code)
Name
Address
How they know you
Years Known
Telephone Number (including area code)
ACKNOWLEDGMENT
I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for my discharge if I become a member or employee. I recognize that completion of this application does not mean that I will be accepted as an employee or member and does not obligate Rose Fire Company to accept me as an employee or member. Applications will remain active for six months, after which time re-application will be necessary. If accepted for employment/membership, I agree to abide by all rules, regulations and policies established by Rose Fire Company and its officers and other persons in charge. I understand that, if accepted as a member, my membership is voluntary and may be terminated in accordance with the Rose Fire Company Bylaws, policies, procedures and all applicable laws and regulations. I understand that, if accepted as an employee, my employment will be "at will" and either I or Rose Fire Company can terminate the employment relationship at any time for any reason or no reason and without prior notice. This application is not an agreement or a contract for employment or membership.

If offered membership or employment and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the duties of employment/membership.

I understand that I may be required to undergo drug screening tests as a condition of employment or membership. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment/membership and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by Rose Fire Company as a condition of my employment/ membership, and I hereby give my consent to the release of all information which Rose Fire Company deems necessary to determine my ability to perform employment/membership duties now or in the future.

I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate termination of my employment/membership with Rose Fire Company.

I hereby authorize Rose Fire Company to investigate my employment/volunteer history with former employers and volunteer organizations and to make any further investigation deemed necessary in connection with my application for employment/membership, including a criminal history check, driving history check, child abuse clearance check, elder abuse clearance check, FBI background check, and other such inquiries. I release Rose Fire Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.

I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded, my employment/membership with Rose Fire Company may be terminated.
Applicant's Signature:
Printed Name:
Signature of Parent or Legal Guardian (if under 18):
 

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