HomeMy Public PortalAboutFire Dept. Employment Application APPLICATION FOR EMPLOYMENT
TO APPLICANT: We deeply appreciate your interest in our organization. Thank you for taking the time to complete this application.
The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law
also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation
in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well as
some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual
orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to credit data. This list, however, is
not exhaustive of the grounds on which discrimination is prohibited.
(PLEASE PRINT PLAINLY)
PERSONAL Date
Name
Last First Middle
Address
No. Street city State ZIP
Are you a US Citizen? Yes_ No
Are you legally eligible for employment in the USA? Yes_ No_ If hired,you are required to submit proof of
your eligibility to work in the USA.
DOB: Sex M F
Position(s) applied for
Were you previously employed by us? Yes No
If yes, when? In what position?
If your application is considered favorably, on what date will you be available for work?
Are there any other job related experiences, skills, or qualifications which will be of special benefit in the job for
which you are applying?
Have you ever been convicted of a major crime(felony)? Yes No
(Do not answer yes if the conviction has been pardoned, annulled, expunged, sealed or impounded by a court.)
If yes, please give the conviction date and nature of the offense.
(A conviction record will not necessarily bar employment. An application for employment with a sealed record on file with the commissioner or
probation may answer"no record"with respect to an inquiry herein relative to prior arrests,criminal court appearances,or convictions. In addition,any
applicant for employment may answer"no record"with respect to any inquiry relative to prior arrests,court appearances,and adjudications in all cases
of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.)
I hereby authorize the Town of Brewster Fire Department to conduct a CORI check prior to my employment.
Signature: Date:
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Employment History
List below present and past employment, beginning with your most recent
Name and Address of Company FROM TO Weekly Weekly Reason for Name of
and Type of Business Startin Sala Last Sala Leavin Supervisor
Mo. Yr. Mo. Yr.
Describe the work you did:
Telephone:
You may contact this employer Yes No
Name and Address of Company FROM TO Weekly Weekly Reason for Name of
and Type of Business Startin Sala Last Sala Leavin Supervisor
Mo. Yr. Mo. Yr.
Describe the work you did:
Telephone:
You may contact this employer Yes No
Name and Address of Company FROM TO Weekly Weekly Reason for Name of
and Type of Business Startin Sala Last Sala Leavin Supervisor
Mo. Yr. Mo. Yr.
Describe the work you did:
Telephone:
You may contact this employer Yes No
Name and Address of Company FROM TO Weekly Weekly Reason for Name of
and Type of Business Startin Sala Last Sala Leavin Supervisor
Mo. Yr. Mo. Yr.
Describe the work you did:
Telephone:
You may contact this employer Yes No
Name and Address of Company FROM TO Weekly Weekly Reason for Name of
and Type of Business Startin Sala Last Sala Leavin Supe isor
Mo. Yr. Mo. Yr.
Telephone: Describe the work you did:
You may contact this employer Yes No
RECORD OF EDUCATION
Circle Last Did you
School Name and Address of School Course of Year Completed Graduat List Diploma or Degree
Study e
Elementary
5 6 7 8 Y
N
High School 9 10 1 12
1
Y
N
College
1 2 3 4
Y
N
FIRE/RESCUE SERVICE & EXPERIENCE
A. Experience
Are you now, or have you ever been a career or call member of any Fire Dept. or Rescue Squad?
Dept. Name/Address
Position Held/Attained:
PERSONAL REFERENCES (Not Former Employers or Relatives)
Name and Occupation Address Phone Number
May we telephone you to follow up on this application at home? Yes No
If yes, what is the best time to call?
May we telephone you to follow up on this application at work? Yes No
If yes, what is the best time to call?
What is your home phone number?
What is your business telephone number?
Do you have a mobile/cell phone number?
E-Mail
Under Massachusetts Law it is unlawful in Massachusetts to require or administer a lie detector test
as a condition of employment or continued employment. An employer who violates this law shall be
subject to criminal penalties and civil liability.
Signature of Applicant
PLEASE READ AND SIGN BELOW
I understand that if accepted by the department for employment, I have an obligation to complete certain
required training programs. To the best of my ability, I will uphold my responsibilities as a member of the
Brewster Fire Department, and continually put forth my best effort.
The facts set forth in my application for employment are true and complete. I understand that if employed, any
false statement on this application may result in my dismissal. I further understand that this application is not
and is not intended to be a contract of employment, nor does this application obligate the employer in any way if
the employer decides to employ me. I understand and agree that my employment is at-will and can be
terminated by either party with or without notice, at any time, for any reason or no reason. No one other than
an officer 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 and then only in writing signed by an officer.
Signature of Applicant
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