SAN MIGUEL FIRE & RESCUE

Employment Application

INSTRUCTIONS (please read carefully): This application is an initial part of the candidate evaluation process. Please apply only if you feel you meet the requirements as described in the recruitment announcement. Reference to information contained in your resume will not be acceptable in lieu of complete answers. Proof of education is required – provide copies of any licenses, diplomas, or certificates you list on this application. Please complete this form digitally, then print and sign.

Position Applying for: Please indicate the position you are applying for
Full Name (Last, First, MI) Last Name, First Name, MI
Home Address Home Address	City City	State State	Zip Code Zip
Email Address Email Address
Mailing Address (if different from home address) Mailing Address
Home Phone Number Home Phone	Cell Phone Number Cell Phone	Driver’s License Number Driver’s License Number	State State	Exp. Date Expiration

EDUCATION AND TRAINING

Name and location of High School: High School

Highest Grade Completed: Select Did you receive a diploma? Select

Include all relevant education and training, including college, business, technical and in-service coursework.

School Name Location (city and state)	Dates of Attendance	Units Completed	Major or Area of Study
From Mo / Yr	To Mo / Yr	Sem.	Qtr.
School Name City & State	MM/YY	MM/YY	Units	Units	Major
School Name City & State	MM/YY	MM/YY	Units	Units	Major
School Name City & State	MM/YY	MM/YY	Units	Units	Major
School Name City & State	MM/YY	MM/YY	Units	Units	Major
School Name City & State	MM/YY	MM/YY	Units	Units	Major
School Name City & State	MM/YY	MM/YY	Units	Units	Major
Community Service and/or Volunteer Experience:
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EXPERIENCE

Beginning with your current or most recent position, list all positions you have held for the last 7 years, accounting for periods of unemployment. If additional space is needed, please make copies of this page, or attach additional sheets in a similar format.

From: Select date	Employer: Employer Name
To: Select date	Address: Employer Address
Total: Years / Months	Job Title/Assignment: Job Title
Hours per week: Enter	Duties: Duties
Number Supervised: #
Supervisor’s Name, Title, and Phone: Supervisor’s Name, Title and Phone
Reason for leaving: Reason for leaving
May we contact this employer? Select If “No,” please explain: Enter explanation
From: Select date	Employer: Employer Name
To: Select date	Address: Employer Address
Total: Years / Months	Job Title/Assignment: Job Title
Hours per week: Enter	Duties: Duties
Number Supervised: #
Supervisor’s Name, Title, and Phone: Supervisor’s Name, Title and Phone
Reason for leaving: Reason for leaving
May we contact this employer? Select If “No,” please explain: Enter explanation
From: Select date	Employer: Employer Name
To: Select date	Address: Employer Address
Total: Years / Months	Job Title/Assignment: Job Title
Hours per week: Enter	Duties: Duties
Number Supervised: #
Supervisor’s Name, Title, and Phone: Supervisor’s Name, Title and Phone
Reason for leaving: Reason for leaving
May we contact this employer? Select If “No,” please explain: Enter explanation
From: Select date	Employer: Employer Name
To: Select date	Address: Employer Address
Total: Years / Months	Job Title/Assignment: Job Title
Hours per week: Enter	Duties: Duties
Number Supervised: #
Supervisor’s Name, Title, and Phone: Supervisor’s Name, Title and Phone
Reason for leaving: Reason for leaving
May we contact this employer? Select If “No,” please explain: Enter explanation
From: Select date	Employer: Employer Name
To: Select date	Address: Employer Address
Total: Years / Months	Job Title/Assignment: Job Title
Hours per week: Enter	Duties: Duties
Number Supervised: #
Supervisor’s Name, Title, and Phone: Supervisor’s Name, Title and Phone
Reason for leaving: Reason for leaving
May we contact this employer? Select If “No,” please explain: Enter explanation

CERTIFICATE OF APPLICANT (Read carefully before signing): I hereby certify that all statements made in this application and on all supplemental information provided are true, and I agree and understand that any misstatement of facts may cause disqualification from or forfeiture of employment. I authorize San Miguel Fire & Rescue to make any necessary and appropriate investigations to verify the information provided.

Signature __________________________________________________________________________________ Enter date