HomeMy Public PortalAbout2022_RFD_FullTime_ApplicationFIREFIGHTER APPLICATION
STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY
The Richmond Fire Department is an Equal Employment Opportunity employer and will accept applications,
hire qualified applicants, administer all terms of employment, and make available all benefits and
compensations of employment without regard to race, color, creed, religion, sex, national origin, handicap (as
defined by law), or age (subject to Federal Law Exemption).
No question on this application is intended to secure information to be used in unlawful discrimination.
NAME – Print or Type
Date of Birth
Revision Date: 04/24/2018 1
INSTRUCTIONS
1. Read each item carefully.
2. This form must by typed or printed neatly in ink.
3. All items must be completed and necessary documentation included.
If question does not apply, so state with N/A)
4. If additional space is needed, use the supplemental page at the end of the form, referencing each item.
5. The completed form must be returned to the Richmond Fire Department as instructed.
POLICY REGARDING THE APPLICANT INFORMATION SUMMARY
1. Failure to comply with instructions and policy regarding this phase of the Applicant Screening Process will result in
the rejection of the application.
2. Failure to accurately and truthfully complete this form will result in the rejection of the application.
3. Applicants who are rejected during this phase of the Applicant Screening Process will be notified of their rejection
and the reason(s) for disqualification.
4. Applications will not be accepted without complete addresses, phone numbers and zip codes.
PLEASE ATTACH COPIES OF REQUIRED DOCUMENTATION:
PHOTO IDENTIFICATION (DRIVER’S LICENSE)
COUNTY BIRTH RECORD
HIGH SCHOOL DIPLOMA OR GED CERTIFICATE
HIGH SCHOOL AND COLLEGE TRANSCRIPTS
MILITARY DISCHARGE PAPERS – DD214
ANY OTHER RELEVANT PAPERS (i.e. FIRE/EMS CERTIFICATIONS, CURRENT CPAT CARD, ETC.)
IF YOU NEED ASSISTANCE IN COMPLETING THIS FORM, PLEASE CONTACT
THE CHIEF’S OFFICE AT
765-983-7540
Revision Date: 04/24/2018 2
1. NAME IN FULL (LAST, FIRST, MIDDLE)
2. ALIAS (ES) NICKNAMES(S), MAIDEN NAMES(S)
3. SOCIAL SECURITY NUMBER 4. TELEPHONE #
5. PRESENT ADDRESS: CITY: STATE: ZIP:
6. DATE OF BIRTH (Include copy of County Birth Record)
7. HEIGHT: 8. WEIGHT 9. COLOR OF EYES
10. COLOR OF HAIR: 11. SCARS, MARKS, TATTOO’S
12. ARE YOU A U.S. CITIZEN?
13. MARRIAGE STATUS SINGLE: MARRIED: DIVORCED: WIDOWED: SEPARATED
14. SPOUSE’S NAME (IF APPLICABLE) ADDRESS: (STREET, CITY, and STATE)
15. SPOUSE’S PLACE OF EMPLOYMENT
PERSONAL HISTORY
Revision Date: 04/24/2018 3
16. LIST chronologically all of your residences in the last TEN years. Include residences while attending school, if away from home, and ALL
military addresses, including off base residences.
DATE
From To Number Street City State/Zip Code
17. LIST all schools you have attended from high school level and above. Include all transcripts and diplomas / degrees.
DATE Degree
From To School Name Address Diploma
High Schools
College /
Universities
Others/
Vocational, etc.)
RESIDENCES
EDUCATION
Revision Date: 04/24/2018 4
18. LIST chronologically (most current first) all former and current employers. Include all full-time, part-time and temporary / seasonal work and
all periods of unemployment. Present employers will be contacted prior to any appointment. Make sure that all phone numbers are correct including
extension numbers.
A. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
B. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
C. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
EMPLOYMENT RECORD
Revision Date: 04/24/2018 5
D. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
E. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
F. Employment Dates From To
Name of Company
Address and ZIP Code
Phone Number
Position Held
Name of Supervisor
Final Salary
Reason for Leaving
EMPLOYMENT RECORD – (continued)
Revision Date: 04/24/2018 6
19. Have you ever been discharged, asked to resign, furloughed, or put on inactive status for cause, or subjected to disciplinary action while in any
position (except military)? YES NO
If YES, state the circumstances:
20. Have you ever resigned (quit) after being informed your employer intended to discharge (fire) you for any reason? YES NO
If YES, explain, giving the name and address of employer, approximate date, and reasons for each.
21. Are you registered for Selective Service? YES NO
Selective Service Number:
A. Have you ever served on active duty in the Armed Forces of the United States? YES NO
Branch of Service
Dates of Active Duty (month, day, years):
Serial Number:
Type of Discharge:
B. Are you currently or have you ever been a member of any United States Armed Forces?
Reserve of National Guard Unit? YES NO
If YES, what are your reserve obligation (if any), unit, and location?
C. While in the Military Service were you ever convicted of any offense: YES NO
When?
Explanation:
D. Include a Copy of your DD214 - * No applicant will be automatically rejected because of less than Honorable Discharge (except a
dishonorable one), but the discharge may be considered in connection with other information for rejection purposes. Please explain on a
supplemental page.
MILITARY SERVICE
Revision Date: 04/24/2018 7
22. List ALL vehicle operator’s license you now hold or have held:
Type (Restrictions) State of License Number Expiration
i.e. CDL, Chauffeur’s) Issuance Date:
A. Have you ever been denied issuance of a license or have you ever had your license suspended or revoked? YES NO
If YES, explain fully:
B. Please provide your automobile insurance company carrier and Policy Number:
C. Have you ever had your automobile insurance revoked or have you ever been refused automobile insurance?
23. Have you ever been arrested or detained by a Law Enforcement Agency? YES NO
A. If YES, provide Date(s), Place(s), and Disposition(s) on supplemental page.
B. Have you ever been arrested on a FELONY? YES NO
C. Have you ever been arrested for any charge involving DOMESTIC VIOLENCE? YES NO
D. List ALL traffic related arrests or citations you have received in the last 5 years.
VEHICLE OPERATOR’S LICENSE RECORD
ARREST / FELONY CONVICTION RECORD
Revision Date: 04/24/2018 8
26. Character References (DO NOT include relatives, former employees, or persons living outside the United States). LIST only character
references that have definite knowledge of your qualifications or fitness for the position for which you are applying.
A. LIST CHARACTER references:
NAME TELEPHONE PRESENT ADDRESS / ZIP CODE
27. List memberships in organizations of which you are a member.
REFERENCES
MEMBERSHIPS IN ORGANIZATIONS
Revision Date: 04/24/2018 9
28. List those activities that you have in the past or now actively participate in.
29. Is there any information not mentioned in this application that may reflect on your suitability to perform the duties you may be called upon to
perform, or that might require further explanation?
A. If so, explain
30. Have you ever applied for a position in any governmental agency, including a Fire Department? YES NO
A. List all agencies
NOTE: ALL STEPS, TIMES AND DATES OF THE HIRING PROCESS ARE MANDATORY AND NON-WAIVABLE BY ANY PARTY.
FAILURE TO MEET ANY OF THE STEPS, TIMES OR DATES, WILL AUTOMATICALLY DISQUALIFY THE CANDIDATE.
TARDINESS IN ANY OF THE STEPS WILL DISQUALIFY THE CANDIDATE.
APPLICATIONS AND TEST RESULTS BECOME THE EXCLUSIVE PROPERTY OF THE CITY OF RICHMOND
HOBBIES AND SPORTS
MISCELLANEOUS
Revision Date: 04/24/2018 10
RICHMOND FIRE DEPARTMENT
AUTHORIZATION AND RELEASE
I, (Name) born at
City) (State) (County)
on (Date) , having filed an application for employment with the Richmond Fire Department
hereby apply for a character report and consent to have an investigation made as to my moral character,
professional reputation and fitness for the position of Firefighter and such other information as may be received,
all of which will be reported only to the admitting authority. I agree to give any further information which may
be required concerning my past record. I understand that the contents of my character report are confidential.
I also authorize and request every person, firm, company, corporation, governmental agency, law enforcement
agency, court association or institution having control of any documents, records and other information
pertaining to me, to furnish to the Richmond Fire Department any such information, including documents,
records, files regarding charges or complaints filed against me, including any complaints erased by law, whether
formal or informal, pending or closed, or any other pertinent data, and to permit the Richmond Fire Department
or any of its agents or representatives to inspect and make copies of such documents, records and other
information. The records, however, will not include any information with respect to a juvenile offense.
I hereby release, discharge and exonerate the Richmond Fire Department, its agents and representatives, and
admission agency of the above jurisdiction, its agents and representatives, and any person so furnishing
information from any and all liability for negligence arising out of the furnishing or inspection of such
documents, records, and other information or the investigation made by the Richmond Fire Department.
This authorization may be revoked at anytime, except to the extent that action has been taken in reliance on this
authorization.
Applicant Signature – Written
Applicant Signature – Printed
Revision Date: 04/24/2018 11
If not previously revoked, this authorization will expire upon the expiration of any hiring list compiled as a
result of this application process.
I have read the foregoing document and have answered all questions fully and frankly. The answers are
complete and are true of my own knowledge.
Signature of Applicant (Sign in black ink)
Subscribed and sworn to before me, a Notary Public in the County of , State
of , this day of ,
20 .
Notary Public (Sign in black ink)
My Commission Expires:
Seal or stamp must be affixed to each original.
Revision Date: 04/24/2018 12
WAIVER AND RELEASE
AERIAL CLIMB
THE UNDERSIGNED HEREBY AGREES THAT:
In consideration for the opportunity for , the undersigned, participating in
any rides in or on City of Richmond vehicles or Richmond Fire Department vehicles, the undersigned hereby
forever releases and saves harmless the City of Richmond, Indiana, and/or the City of Richmond Fire
Department, and all and each of its agents, Board members, employees and representatives, both jointly and
severally, from any and all liability, claims and any and all damages, which may be incurred, including personal
injuries sustained or death, as a result of the undersigned participating in any rides in or on the above-described
vehicles. Such release shall include, but not be limited to, any claims which may arise because of a negligent
act or omission by the City of Richmond, The Richmond Fire Department, or any of their agents, employees or
representatives, either jointly or severally; and for any claims, expenses, and damages which might hereafter be
brought, claimed, or instituted for any reason whatsoever.
This agreement shall be binding on all parties to this agreement as well as their heirs, successors, personal
representatives and assigns from and after execution hereof. The City of Richmond or the Richmond Fire
Department has the right to rescind permission of the above activities at any time.
Undersigned:
Signed)
Printed)
Date)
Telephone Number
Address
City State Zip
Revision Date: 04/24/2018 13
AERIAL CLIMB
PLEASE LEAVE THIS PAGE BLANK AS IT WILL BE COMPLETED THE DAY OF THE AERIAL
CLIMB
Authorized Staff Date Permission Granted
Printed Date Permission Expires
5 Days from Above Written Date)
This instrument prepared by the Department of Law, City of Richmond, Indiana
WAIVER AND RELEASE – VOLUNTARY
Revision Date: 04/24/2018 14
All applicants are required to assist and cooperate in obtaining past employment records or personal history
information.
FAILURE TO COOPERATE MAY BE CONSIDERED CAUSE FOR DISQUALIFICATION
If it is found that you have falsified your application, you will be automatically disqualified; or if employed,
may be grounds for immediate discharge.
I have read and understand the above statement.
Printed name of applicant Signature of Applicant
Date
The City of Richmond is an Equal Opportunity Employer
Revision Date: 04/24/2018 15
31. Read the following statement carefully. If you have any questions, please call 765.983.7540 before signing
this form.
I certify that the information contained in this form is correct and complete to the best of my
knowledge. I realize that misrepresentation of the facts is cause for rejection of my application or
dismissal after appointment. I understand that final employment is contingent upon satisfactory
completion of all phases of the Applicant Screening Process.
Signature of Applicant Date of Signature
Printed Signature of Applicant
Subscribed and sworn to before me, a Notary Public in the County of ,
State of , this day of ,
20 .
NOTARY PUBLIC
MY COMMISSION EXPIRES:
SIGNATURE PAGE
Revision Date: 04/24/2018 16
THIS COMPLETED APPLICATION MUST BE RETURNED TO THE:
RICHMOND FIRE DEPARTMENT
101 SOUTH 5TH STREET
RICHMOND INDIANA 47374
32. Review of Application
A. Reviewed By:
B. Date Reviewed:
Revision Date: 04/24/2018 17
Dear Applicant,
The City of Richmond accepts applications for firefighters on a scheduled basis. Some of the basic qualifications and selection
procedures consist of, but are not limited to, the following:
1. In order to be eligible for appointment to the Richmond Fire Department, an applicant must be a resident citizen of
the United States. You must reside within 50 miles of the city of Richmond at the time of appointment to the
Richmond Fire Department I.C. 36-8-4-2
2. Applicant must be at least twenty-one (21) years of age at time of hire. I.C. 36-8-3.5-12
3. Applicant must have not attained the age of thirty-six (36) years at time of hiring I.C. 36-8-3.5-12
4. Applicant shall be a high school graduate as evidenced by a diploma issued by a high school accredited by the
department or agency of a state authorized to accredit high schools. An equivalency diploma (G.E.D.) issued by such
an accredited high school is acceptable.
5. Applicant must hold a valid driver’s license from any state and must be able to acquire a valid Indiana Driver’s
License prior to employment
6. A dishonorable discharge from the military service shall disqualify the applicant.
7. Applicants receiving compensation or pension benefits from military service are not disqualified from applying.
8. Applicants must maintain a reliable contracted phone service. (Land-line and / or cell phone)
9. Applicants shall not have been convicted of a felony.
10. Applicant must be able to successfully complete both the extensive physical ability test and written aptitude
examination.
11. Applicant must be able to pass a thorough background investigation.
12. Applicant must submit to a Structured Oral Interview.
13. Applicant shall not have made any illegal delivery of drugs.
14. Applicant shall not have participated in any illegal use of any type of drugs.
15. Applicant must obtain Firefighter I & Firefighter II within first 12 months of hire.
16. Applicant must obtain EMT within first year of hire, and Paramedic within 5 years of hire.
STATEWIDE BASELINE VISION STANDARDS
1. Vision testing as follows:
a. Far Vision acuity
1) Corrected binocular vision worse than 20/30;
2) Corrected vision of the worse eye worse than 20/50; or
3) Uncorrected binocular vision worse than 20/200, with the exception that long term successful users of soft
contact lenses do not have to meet this uncorrected standard.
b. Color vision – an inability to identify red, green and yellow colors.
c. Peripheral vision – uncorrected field -of-vision less than one hundred forty degrees (140) in the horizontal
meridian in each eye.
CPAT INFORMATION
ESEC Emergency Services
700 N. High School Road
Indianapolis, Indiana 46241
317.988.7703
317.248.7931 (fax)
www.wayne.k12.in.us/esec/
Revision Date: 04/24/2018 19
SUPPLEMENTAL PAGE
Revision Date: 04/24/2018 20
SUPPLEMENTAL PAGE (continued)
Revision Date: 04/24/2018 21
ADDITIONAL ITEMS TO BE INCLUDED WITH YOUR APPLICATION:
Criminal background investigation – can be obtained at your local and/or county police department
License check – from your local BMV (will probably have to get it on line)
Credit Check – can be obtained on-line from any of the 3 major credit reporting agencies or from your local
credit union (if you are a member of one)
Revision Date: 04/24/2018 22
Richmond Police Department
Records Division
Please be advised, this is a local (Richmond) record check only. If you desire state and county record
checks, you must contact those agencies for that additional information.
50 North 5th Street
Richmond, IN
765-983-7247
APPLICANT FULL NAME:________________________________________________________________
PRESENT ADDRESS:_____________________________________________________________________
CITY, STATE, ZIP CODE:_________________________________________________________________
ALIAS AND/OR OTHER NAMES (MAIDEN):________________________________________________
DATE OF BIRTH:_______________ SOCIAL SECURITY#:___________________________
TODAY’S DATE______________
I, ___________________________________, HEREBY GIVE AUTHORIZATION TO THE RICHMOND,
INDIANA POLICE DEPARTMENT TO RELEASE ANY INFORMATION CONCERNING MY RECORD
AND/OR ARRESTS, OR PENDING WARRANTS THAT I MAY HAVE.
_______________________________
APPLICANT SIGNATURE
(BELOW PORTION TO BE FILLED OUT BY RECORDS CLERK ONLY)
DOES APPLICANT HAVE A RECORD? _____YES _____NO
See Additional _____of pages of record.
COMMENTS:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________ ___________
RECORD’S CLERK SIGNATURE DATE
P: 765-935-5655 F: 765-935-6164 Email: vanvleet@vanvleetinsurance.com
Dept.__________
DISCLOSURE CONSENT
FOR PROCUREMENT OF
MOTOR VEHICLE REPORT FOR
EMPLOYMENT & DRIVING PURPOSES
The undersigned hereby authorizes City of Richmond, or its insurance agency,
VanVleet Insurance, or its assigns, to obtain copies of Motor Vehicles, pertaining
to me for employment &/or driving purposes, and for use in rating and/or
underwriting insurance for which the above names employer may apply, and any
renewal thereof.
DATE:______________________ SIGNED: ________________________________
____________________________ _________________________________________
Date of Birth Printed Name
____________________________ _________________________________________
Driver’s License Number State of Issue
For Office Use Only:
______ Approved
______ Watch Basis
______ Not Approved
Valid Class A CDL / Class B CDL ______ _____
YES NO
Type of Endorsements: _______________________________________________________
APPLICANT CHECK LIST
Please use the following list as a guide in completing your application. Use copies only, not originals.
Certified Copy of Birth Certificate
Addresses and dates pertaining to all prior residences in the last ten (10) years
High School Transcripts, Diploma (optional) showing graduation date, GED Diploma
and College Transcripts, Diploma (optional) (copies only)
Information pertaining to all present and former employers, (date, names,
addresses, zip codes & phone numbers of Company)
Dates of military active duty, serial number and reserve obligation – DD214 Form if
applicable (copy only)
State Certifications (if applicable) and/or CPAT Card if already obtained
Type, expiration date, number and restrictions relating to Driver's License - Copy of
current driver's license
Dates, locations, descriptions of any vehicle accident in the last five (5) years. Note any
citations
The date, place, charge and the disposition of any arrest (Adult/Juvenile), local/non-local
Information relating to three (3) to five (5) personal references (names, address,
telephone number during the day, occupation, length of time known and zip code)
References shall not include relatives or former/current employers
Authorization and Release Forms
Waivers
THIS COMPLETED APPLICATION MUST BE RETURNED TO:
RICHMOND FIRE DEPARTMENT
101 SOUTH 5TH STREET
RICHMOND, INDIANA 47374
Revision Date: 04/24/2018 25