[Village of Sussex] PT Firefighter/Paramedic or Firefighter/EMT

Application for Employment: Firefighter/Paramedic
Part-Time or Paid-on-Call

EQUAL OPPORTUNITY EMPLOYER

This document must be completed fully and signed in order to be considered a legitimate employment application.
All applicants must submit a completed employment application, letter of interest and resume in order for this to be considered a legitimate employment application.

Part-time or Paid-on-call?

Last Name

First Name, Middle Initial

First Name *

Middle Initial *

Your Email Address

Home Phone

Cell Phone

May we call you at work?

Work Phone

How do you prefer that we contact you?

How did you learn about this position?

Are there any other names under which you have worked for attended school?

Other Names

Are you legally eligible for employment in the United States? (If hired, you will be required to provide proof of work authorization.)

If you are under 18 years of age, can you provide required proof of eligibility to work?

Have you ever applied to the Village of Sussex before?

Position(s) Applied For and Date(s)

Do you have any relatives working at the Village of Sussex?

What is their relationship to you and in what department are they employed?

Are you able to perform all essential functions/duties of the position for which you are applying?

If no, please identify which essential functions you could perform with reasonable accommodation:

Are you licensed with any group, association or society relating to the position for which you are applying?

If yes, specify: License No., Expiration Date, Issuing Organization

Have you ever been convicted of a misdemeanor, gross misdemeanor or felony or do you currently have a pending criminal charge against you?

Conviction record(s) or pending arrest record(s) do not constitute an automatic bar to employment and will be considered only if there is a substantial relationship to the circumstances of the particular position or if the employer deems there is a bona fide occupational qualification inherent in the position.

Please explain and include dates

Education

High School Graduate?

Number of years completed?

Trade/Apprenticeship/Vocation School

Name & Location

# Years Completed/Area of Study

Degree/Diploma

Undergraduate School

Name & Location

# Years Completed/Area of Study

Degree/Diploma

Graduate School

Name & Location

# Years Completed/Area of Study

Degree/Diploma

FIRE & RESCUE EXPERIENCE

Firefighter/Paramedic applicants must attach:

Copy of State of Wisconsin Paramedic License
Copy of Current BLS Card
Copy of Current ACLS Card
Copy of Firefighter I Certification
Letter of Interest
Resume

You will have the opportunity to upload documents at the end of the application.

Fire Department/Company 1 Name

Fire Department/Company 1 Dates of Employment

Start Date

End Date

Fire Department/Company 1 Supervisor

Name

Phone

Fire Department/Company 1 Description of Duties

May We Contact Fire Department/Company 1?

Fire Department/Company 2 Name

Fire Department/Company 2 Dates of Employment

Start Date

End Date

Fire Department/Company 2 Supervisor

Name

Phone

Fire Department/Company 2 Description of Duties

May We Contact Fire Department/Company 2?

Fire Department/Company 3 Name

Fire Department/Company 3 Dates of Employment

Start Date

End Date

Fire Department/Company 3 Supervisor

Name

Phone

Fire Department/Company 3 Description of Duties

May We Contact Fire Department/Company 3?

EMPLOYMENT RECORD

Begin with the most recent employer. Do not write, "See resume," or similar. Attach additional sheets if necessary.

Employer 1 Name & Address

Employer 1 Dates of Employment

Start Date

End Date

Your Title at Employer 1

Employer 1 Supervisor

Name

Title

Phone

Employer 1 Description of Duties

Employer 1 Salary

Starting Salary

Last Salary

Reason for Leaving Employer 1 or Seeking Other Employment

May We Contact Employer 1?

Employer 2 Name & Address

Employer 2 Dates of Employment

Start Date

End Date

Your Title at Employer 2

Employer 2 Supervisor

Name

Title

Phone

Employer 2 Salary

Starting Salary

Last Salary

Reason for Leaving Employer 2 or Seeking Other Employment

May We Contact Employer 2?

Employer 3 Name & Address

Employer 3 Dates of Employment

Start Date

End Date

Your Title at Employer 3

Employer 3 Supervisor

Name

Title

Phone

Employer 3 Salary

Starting Salary

Last Salary

Reason for Leaving Employer 3 or Seeking Other Employment

May We Contact Employer 3?

EMPLOYMENT REFERENCES

List individuals familiar with your job qualifications. No relatives or personal friends.

Employment Reference 1

Name *

Relationship *

How long known? *

Employment Reference 1

Address

Day Phone

Evening Phone

Employment Reference 2

Name *

Relationship *

How long known? *

Employment Reference 2

Address

Day Phone

Evening Phone

Employment Reference 3

Name *

Relationship *

How long known? *

Employment Reference 3

Address

Day Phone

Evening Phone

Upload Files: Firefighter/Paramedic applicants must attach:</B) • Copy of State of Wisconsin Paramedic License • Copy of Current BLS Card • Copy of Current ACLS Card • Copy of Firefighter I Certification • Resume • Letter of Interest Attach additional sheets, if necessary, to provide additional information. NOTE: All files must be selected before you click the "Upload" button. Once you have clicked "Upload," you cannot go back and attach additional files.

Click Here to Upload

Applicant’s Authorization & Acknowledgement: I certify that the information provided on this application (and accompanying documentation, if any) is true, correct and complete to the best of my knowledge without omissions of any kind. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be justification for dismissal if discovered at a later date. I authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying documentation, if any) to provide any relevant information to the Village of Sussex that may be required to enable the Village of Sussex to arrive at an employment decision. I release the Village of Sussex and all providers of information from any liability as a result of furnishing and receiving any information related to the Village of Sussex hiring process. I understand that I may be required to submit to a pre-employment physical examination, including substance abuse screening, prior to appointment. I agree that the results of such examinations and screening may be released to the Village of Sussex only for consideration of my employment. I acknowledge that a full background check may be run as related to any police records and/or driving records. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the Village of Sussex is of an at will nature. I understand that if I am hired, I am required to abide by all rules and regulations of the Village of Sussex. I understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the Village.

I agree

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Application for Employment: Firefighter/ParamedicPart-Time or Paid-on-Call

EQUAL OPPORTUNITY EMPLOYER

This document must be completed fully and signed in order to be considered a legitimate employment application. All applicants must submit a completed employment application, letter of interest and resume in order for this to be considered a legitimate employment application.

Education

FIRE & RESCUE EXPERIENCE

EMPLOYMENT RECORD

EMPLOYMENT REFERENCES

Application for Employment: Firefighter/Paramedic
Part-Time or Paid-on-Call

This document must be completed fully and signed in order to be considered a legitimate employment application.
All applicants must submit a completed employment application, letter of interest and resume in order for this to be considered a legitimate employment application.