PERSONAL INFORMATION

Last Name: First : M.I.

Permanent Address:

Current Address:

Permanent Phone: ( ) Current Phone ( )

Work Phone: ( ) E-Mail:

Emergency Contact: Phone ( )

EDUCATION

Highest grade completed in school: Location:

CPR Certification: Yes q No q Expiration Date:

RELATED WORK EXPERIENCE

Have you any other experience working in the field of health care? Yes q No q

If yes, in what capacity and how long?

Supervisor: Phone No. ( )

Please list any information/skills you think might be of help in considering your application.

REFERENCES:

Excluding family members, personal friends. Examples: employers, volunteer affiliates, religious leaders and/or volunteer organizations.

Name: _____

Address: ______________________________________________________________________

City, State: Phone No. ( )

Name: ____________

Address: ______________________________________________________________________

City, State: Phone No. ( )

Name: ______

City, State: Phone No. ( )

CRIMINAL INFORMATION

Have you ever been convicted of a crime? *Yes q No q

Do you have any pending criminal charges awaiting disposition at this time? *Yes q No q

*If you answered yes to either question, please provide information on arrest, nature of each charge or conviction, related circumstances and final disposition on a separate page. Include dates and any other necessary information.

Please note: A criminal background check will be conducted prior to employment.

MISCELLANEOUS

How did you hear about the River Falls Area First Responders organization, and what are your expectations for involvement?

________________________________________________________

AUTHORIZATION

“I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that any falsification, misrepresentation or omission shall be grounds for dismissal from the service.”

Signed: Date:

Do you wish to have your application kept on file if there are no openings at this time?

Yes q No q

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For Office Use Only Application Received: .

Interview Date: Check out procedure

Approval Date: Resignation Letter:

Begin class: _____ _____ Return vest:

Certification date: Return supplies:

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