Job Application

ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATION ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.

Position Sought:*

How Did you learn about the position?

Full Name*

First Name Middle Name Last Name

Current Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone:*

Area Code Phone Number

Mobile Phone:*

Area Code Phone Number

Mobile Phone Carrier:*

Email Address*

A copy of this completed application will be emailed to the above address.

Date of Birth*

MonthDay Year

Social Security Number:*

Driver's License Number*

Start date

MonthDay Year

Desired Wage/Salary per hour:

	Yes	No
1) Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restriction?
2) Have you ever been involuntarily terminated or asked to resign from any position of employment?
3) If Selected for employment, are you willing to submit to a pre-employment drug screening test?

If you answered Yes to question 2 above please explain:

Education

	School Name	Location	Years Attended	Degree Received	Major
Elementary
High School
College
Tech School
Misc.

Other Training, Certifications, or licenses held:

List other information pertinent to employemnt you are seeking:

Employment History:

	Employer	Job Title	Dates Employed	Address	Phone	Supervisor	Starting Salary	Ending Salary	Duties Performed	Reason for leaving
1
2
3
4
5
6
7
8
9
10

Military Experience?*

Rank:

Military Begin

MonthDay Year

Military End

MonthDay Year

ACKNOWLEDGMENT AND AUTHORlZATION

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as
may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed
45 days. Any applicant wishing to be considered for employment beyond this time period
should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any
employment relationship with this organization is of an "at will" nature, which means that
the Employee may resign at any time and the Employer may discharge Employee at any time
with or without cause. It is further understood that this" at will" employment relationship
may not be changed by any written document or by conduct unless such change is
specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my
application or interview(s) may result in discharge. I understand, also, that I am required to
abide by all rules and regulations of the employer.

Signature

APPLICANT’S STATEMENT AND AUTHORIZATION

In connection with my application for employment with the Village of New Richmond, Ohio,
I hereby certify that the information set forth above is accurate and I further authorize the
Village of New Richmond, Ohio and its authorized agents or employees to investigate my
background including the verification of the information set forth above. I further authorize
the Village of New Richmond, Ohio and its authorized agents and employees to contact and
obtain information from my former employers, all public agencies, including federal, state
and local law enforcement offices, sheriff's offices, the bureau of worker's compensation, the
bureau of employment compensation, the bureau of vocational rehabilitation, the department
of motor vehicles, schools, and courts, and consumer reporting agencies to obtain
information concerning my fitness for employment with the Village of New Richmond, Ohio.

I further authorize each of the above entities and all public agencies, listed or not, to release
to the Village of New Richmond, Ohio and its authorized agents and employees, all
information which the entity or public agency has concerning me, including, without
limitation any and all files maintained by that entity or public agency and further authorize
that agency or public entity to release these files or to the Village of New Richmond, Ohio
and its authorized agents and employees and/or to allow the files to be copied by the Village
of New Richmond, Ohio or its authorized agents or employees. In addition, I also authorize
review of this information in the future.

In addition, I hereby authorize the Village of New Richmond, Ohio and its authorized agents
and employees to use a copy of this AUTHORIZATION AND RELEASE to gain access to the
information and for the entity or public agency to maintain a copy of this form with files
maintained by that entity or agency. Finally, I hereby release and agree to hold harmless, the
Village of New Richmond, Ohio and its authorized agents or employees and any entity or
public agency acting in reliance on this AUTHORIZATION AND RELEASE, from any claim
whatsoever arising out of the use of this form and the release of information to the Village of
New Richmond, Ohio and its authorized agents and employees.

THIS AUTHORIZATION AND RELEASE SHALL EXPIRE SIX MONTHS FROM THE DATE
OF SIGNING.

Signature

New Richmond Fire & EMS Job Application