LITCHFIELD FIRE RESCUE

LITCHFIELD FIRE RESCUE
Litchfield Fire Rescue is an equal opportunity employer. This application will not be used for limiting or excluding

any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company

Please fill out all of the sections below:
Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Email*
example@example.com
Date

MonthDayYear
Date
Employment Position

Position(s) applying for: On-Call Firefighter/EMT (part time)
How did you hear about this position?
What days and hours are you available for work?
On what date can you start working if you are hired?

MonthDayYear
Date
Do you have reliable transportation to and from work?*

YesNo
Personal Information
Have you ever applied to or worked for the Town of Litchfield, NH before?*

YesNo
If yes, when?
Do you have any friends, relatives, or acquaintances working for Litchfield Fire Rescue*

YesNo
If yes, state name & relationship:
Are you 18 years of age or older?*

YesNo
Are you a U.S. citizen or approved to work in the United States?*

YesNo
What document can you provide as proof of citizenship or legal status?
Do you have any condition which would require job accommodations?*

YesNo
If yes, please describe accommodations required below.
Have you ever been convicted of a criminal offense (felony or misdemeanor)?*

YesNo

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

	DATE	CHARGE	CITY/STATE	POLICE AGENCY	DISPOSITION

Have you ever been arrested or taken into police custody for outstanding warrants?*

YesNo
Have you ever been involved as a party in civil litigation?*

YesNo
If yes, to either question, please explain.
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the positions applied for may, however, be considered)
Traffic History
Current driver’s license number*
State Issued:*
Name of automobile insurance company:*
Has your DL ever been suspended or revoked for any reason?*

YesNo
If yes, please give date, location and reason.
Traffic Violation Record
Have you received any traffic/motor vehicle violations in the last three years?*

YesNo

If yes, please list all violations you have received in the preceding three years in this or any other state or country excluding parking tickets Include DO violations, seat, no insurance, inspection, all moving violations, etc. List the disposition of each, such as dismissed, paid fine, defensive driving, etc.

	DATE	CHARGE	CITY/STATE	POLICE AGENCY	DISPOSITION

Have you ever been convicted for driving while intoxicated or under the influence?*

YesNo
If yes, please explain.
Accident Record
Have you been involved in a motor vehicle crash in the last three years?*

YesNo

If yes, please list all accidents in which you were involved as a driver during the preceding three years in this or any other state or country:

	DATE	Nature	# OF FATALITIES	# OF PERSONS INJURED

Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying
(Note: Litchfield Fire Rescue complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )
Education and Training
High School
Name
Location (City, State)
Year Graduated
Degree Earned
College/University
Name
Location (City, State)
Year Graduated
Degree Earned
Vocational School/Specialized Training
Name
Location (City, State)
Year Graduated
Degree Earned
Military
Are you a member of the Armed Services?*

YesNo
If yes, what branch?
What was your military rank when discharged?
How many years did you serve in the military?
Previous Employment
Employer Name
Job Title
Supervisor Name
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Employer Telephone
Dates Employed

MonthDayYear
Date
Reason for leaving
Employer Name
Job Title
Supervisor Name
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Employer Telephone
Dates Employed

MonthDayYear
Date
Reason for leaving
Employer Name
Job Title
Supervisor Name
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Employer Telephone
Dates Employed

MonthDayYear
Date
Reason for leaving
References

Please provide 3 personal and professional reference(s) below:

	Reference	Contact Details
Reference #1
Reference #2
Reference #3

Applicants are encouraged to provide a resumè and include copies of any certifications relevant to the position they are applying for.
AT-Will Employment

The relationship between you and the Town of Litchfield is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Town of Litchfield. No representative of Litchfield Fire Rescue has the authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you, the Fire Chief, and the Litchfield Town Administrator or Board of Selectmen.
By signing below, I certify that all information given on this application is true, correct and complete to the best of my knowledge. I also certify that I have accounted for all of my work experience and training on this application. I have not knowingly withheld any fact or circumstance, which would, if disclosed, affect my application unfavorably.
Applicant Signature*

Clear
Dated

MonthDayYear
Date
Attachments & Addendums
Should be Empty:

LITCHFIELD FIRE RESCUE

Applicant Information

Personal Information

Traffic History

Traffic Violation Record

Accident Record

Job Skills/Qualifications

Education and Training

High School

College/University

Vocational School/Specialized Training

Military

Previous Employment

References