911 Application

*Please complete and click submit.

911 Division Application for Employment

Pre-Employment Questionnaire: An Equal Opportunity Employer

Personal Information

• Date *
• Name *(Last Name First)
• Social Security Number *
• Current Address *
• Permanent Address
• Phone Number *
• Secondary Phone Number
• Referred by:

Employment Desired

• Position Applied For *
• Date You Can Start *
• Salary Desired *
• Are you employed now! *
• If so, may we inquire of your present employer? YesNo
• Have you applied here before? *YesNo
• If so, when?

Education History

• Name and Location of High School *
• Years Attended *
• Did you graduate? *YesNo
• Subjects Studied
• List additional high schools attended, if applicable.
• Name and Location of College
• Years Attended
• Did you graduate? YesNo
• List major/minor and subjects studied
• Name and Location of Trade, Business or Correspondence School
• Years Attended
• Did you graduate? YesNo
• Subjects Studied

General Information

• List any subjects of special study/research work
• Special Training
• Special Skills
• US Military or Naval Service
• Rank

Former Employers

• List below your last four employers, starting with last one first.
• Employer 1: Name and Address
• Employer 1: List Dates Employed
• Employer 1: Salary and Position
• Employer 1: Reason for Leaving?
• Employer 2: Name and Address
• Employer 2: List Dates Employed
• Employer 2: Salary and Position
• Employer 2: Reason for Leaving?
• Employer 3: Name and Address
• Employer 3: List Dates Employed
• Employer 3: Salary and Position
• Employer 3: Reason for Leaving?
• Employer 4: Name and Address
• Employer 4: List Dates Employed
• Employer 4: Salary and Position
• Employer 4: Reason for Leaving?

References

• Please list three people you are not related to, whom you have known at least one year.
  Please include Name, Address and Occupation of Reference, and number of years known.
• What is your email address?

AUTHORIZATION "I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE,.

I AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION. I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT.

FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE. THIS WAIVER DOES NOT PERMIT THE RELEASE OR USE OF DISABILITY-RELATED OR MEDICAL INFORMATION

IN A MANNER PROHIBITED BY THE AMERICANS WITH DISABILITIES ACT (ADA) AND OTHER RELEVANT FEDERAL AND STATE LAWS. I UNDERSTAND THAT A CONSUMER CREDIT REPORT OR CRIMINAL RECORDS CHECK MAY BE NECESSARY PRIOR TO MY EMPLOYMENT. IF SUCH REPORTS ARE REQUIRED,

I UNDERSTAND THAT, IN COMPLIANCE WITH FEDERAL LAW, THE COMPANY WILL PROVIDE ME WITH A WRITTEN NOTICE REGARDING THE USE OF THESE REPORTS AND WILL ALSO OBTAIN A SEPARATE WRITTEN AUTHORIZATION FROM ME TO CONSENT TO THESE REPORTS. I ALSO UNDERSTAND THAT

IN COMPLIANCE WITH FEDERAL LAW, THE COMPANY WILL PROVIDE ME WITH A WRITTEN NOTICE REGARDING THE USE OF THESE REPORTS AND WILL ALSO OBTAIN A SEPARATE WRITTEN AUTHORIZATION FROM ME TO CONSENT TO THESE REPORTS. I ALSO UNDERSTAND THAT A POOR CREDIT HISTORY OR

CONVICTION WILL NOT AUTOMATICALLY RESULT IN DISQUALIFICATION FROM EMPLOYMENT." IN COMPLIANCE WITH FEDERAL LAW, ALL PERSONS HIRED WILL BE REQUIRED TO VERIFY IDENTITY AND ELIGIBILITY TO WORK IN THE UNITED STATES AND TO COMPLETE THE REQUIRED EMPLOYMENT

ELIGIBILITY VERIFICATION DOCUMENT FORM UPON HIRE.

• Please type your full name and date. *

Criminal History Record Information Consent/Inquiry Form

• Enter Full Name *
• Email *
• Address *
• Sex *
• Race *
• Date of Birth *
• Phone *
• Write your valid authorization for 90 days, or 180 days here: *
• Social Security Number
• I hearby give consent to the above named to perform periodic criminal history backgound check for the duration of my employment with this agency.
• Electronic Signature Type your full name here for your signature.

 

Verification

• Please enter any two digits *Example: 12
• This box is for spam protection - <strong>please leave it blank</strong>:

Printable Forms

Application with Background Check

CHRI Form