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2. Date
4. First Name
5. Middle Name
6. Last Name
8. Mailing Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Cell / Other Phone
17. Email Address
18. States*
20. City of Birth
21. County of Birth
23. States*
24. Country
26. Have you been convicted of a felony with the last 7 years?*

    1. Yes
    2. No
28. Please explain*
30. Have you ever filed an application with us before?

    1. Yes
    2. No
32. Application Dates
34. Have you ever been employed by us before?

    1. Yes
    2. No
36. Please list dates of employment
38. Do you have any relatives working for us?

    1. Yes
    2. No
40. Please list names
42. High School Name
44. Mailing Address
46. City
47. State
48. Zip Code
50. From Date Attended High School
51. To Date Attended High School
53. Year Completed
55. Did you graduate?

    1. Yes
    2. No
57. College University Name
59. Mailing Address
61. City
62. State
63. Zip Code
65. From Date Attended College
66. To Date Attended High School
68. Did you graduate?

    1. Yes
    2. No
70. Type of Degree
72. Other Schools (Trade, Vocational, Business, Police Academies or Military)
74. Mailing Address
76. City
77. State
78. Zip Code
80. From Date Attended School
81. To Date Attended School
83. Area of Study
85. Did You Graduate

    1. Yes
    2. No
87. Have you completed an IFSAC approved Fire Fighter I and Firefighter II course that resulted in certifications?

    1. Yes
    2. No

    Proof of Certification must be submitted upon request.

89. Computer Skills

    1. Word
    2. Excel
    3. Outlook
    4. PowerPoint
91. Type of Degree of Certificate
92. General Computer Knowledge

    1. Basic
    2. Advanced
94. State approximate number of words per minute: Typing
96. Do you speak, read, or write any foreign languages?

    1. Yes
    2. No
98. Which languages?
100. On what date are you available to work?
104. Please enter the details of your last 3 employers
106. Company / Name*
107. Phone
109. Mailing Address
111. City
112. State
113. Zip Code
115. Your Position
117. Duties
119. Date Employment Started
120. Date Employment Ended
122. Reason for Leaving
123. Starting Salary
125. Ending Salary
126. Supervisor Name
128. Supervisor Title
129. May we contact the Supervisor?

     1. Yes
     2. No
133. Company / Name*
134. Phone
136. Mailing Address
138. City
139. State
140. Zip Code
142. Your Position
144. Duties
146. Date Employment Started
147. Date Employment Ended
149. Reason for Leaving
150. Starting Salary
152. Ending Salary
153. Supervisor Name
155. Supervisor Title
156. May we contact the Supervisor?

     1. Yes
     2. No
160. Company / Name*
161. Phone
163. Mailing Address
165. City
166. State
167. Zip Code
169. Your Position
171. Duties
173. Date Employment Started
174. Date Employment Ended
176. Reason for Leaving
177. Starting Salary
179. Ending Salary
180. Supervisor Name
182. Supervisor Title
183. May we contact the Supervisor?

     1. Yes
     2. No

187. The Fire Department is an Equal Employment Opportunity/ Affirmative Action Employer. We consider applicants for all positions without regard to race, color, natural origin, sex, age, handicap, marital status, religion, or any other legally protected status.

     I understand that my appointment or employment will be contingent upon the results of a completed background investigation. I am aware that any omission, falsification, misstatement or misrepresentation will be the basis for my disqualification as an applicant or my dismissal from the Carthage Fire Department. I agree to the conditions and certify that all statements made by me on this application are true, correct and complete, to the best of my knowledge. I understand that this employment application shall become the property of the Carthage Fire Department.

     I further understand and agree that my employment or appointment will be contingent upon the results of a complete drug test and that I may be required to take drug test during the term of my employment or appointment with the Carthage Fire Department.

     I understand that the use of drugs and alcohol is not permitted, during work or duty time, whether paid or unpaid, in the areas, including vehicles, where work is performed by employees or appointees.

     I further authorize the Carthage Fire Department or an agent of the Carthage Fire Department, without need of further authorization, to obtain medical records allowed by law if I claim rights to payment or receipt of any benefit pursuant to state or federal law.

     I further agree to give any authorization as may be required by the Health Insurance Portability Accountability Act of 1996 (HIPAA) for health care providers to release the necessary medical information to process my application for employment.

     I understand and agree that any employment or appointment offered to me will be contingent upon my acceptance of compensatory time off, instead of cash, in payment for overtime hours that I work, to the extent allowed by law. I understand, however, that the Carthage Fire Department has the absolute discretion to periodically substitute cash, in whole or part, for my accrued compensatory time.

     I authorize any of the persons or organizations referenced in this application to furnish information, personal or otherwise, regarding my ability and fitness for employment or appointment with the Carthage Fire Department and I release all such parties from any and all liability for any damage that might result from furnishing such information to the Carthage Public.

     I agree to conform to the rules, regulations, and orders of the Carthage Fire Department and acknowledge that these rules, regulations, and orders may be changed, interpreted, withdrawn, or added to by the Carthage Fire Department, as its discretion, at any time and without any prior notice to me.

189. You must agree to the disclosure statement provided in order for us to accept your application.*

     1. Yes I Agree
Leave This Blank:


191. 1. Receive an email copy of this form.
192. Email address

     This field is not part of the form submission.

193. Submit

* indicates a required field