Employment Application – Magnolia Fire Department

Personal DataStep 1 of 10

Montgomery County Emergency Services District #10

Position Applying For: *

Instructions

Each question should be fully and accurately answered. No Action can be taken on this application until all questions have been answered. All Information you give on this application will be held in strict confidence.

Last Name *

First Name *

Middle Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Home Phone

Mobile Phone *

Email *

Social Security Number *

Are you at least 18 years old? *

Date of Birth *

Driver's licenses Number *

State *

Class *

Restrictions *

Photocopy of DL *

Drop your file here or click here to upload

EMS Certification (Level) *

TDSHS Licenses Number *

Fire Certification (Level) *

TCFP Number *

Upload a Copy of your EMS Certification

Drop your file here or click here to upload

Upload a Copy of your TCFP Certification

Drop your file here or click here to upload

Have you ever been convicted of a felony or misdemeanor? (Except a minor traffic violation) *

Explain

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. If you worked in any position under another name, please give name(s). Please give month and year.

Do you have any other known names other than the one on this application? *

Please list all names you have gone by and the years:

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

Do you have other work history?

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

1 Do you have other work History? *

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

Emergency Contact Information

Last Name *

First Name *

Relationship *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

High School Name and Location

Did You Graduate with a Diploma? *

What Year? *

GED? If So what Year

Leave Blank if no GED

College or University:

Did you Graduate?

Major

Degree Type

How many hours do you have?

Additional Education/Vocational/Technical Training Completed:

School

Personal Skills

Please indicate briefly any job-related skills or additional information you feel may be helpful to us in considering your application:

Give three references, not relatives or former employers.

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION *I do hereby authorize a review of and full disclosure of all records concerning myself by any duly authorized agent of Montgomery Emergency Service District #10, whether the said records are public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of the records of Former Employees, educational institutions, financial or credit institutions, medical and psychiatric institutions

CRIMINAL AND DRIVING RECORDS RELEASE *I authorize the Montgomery County Emergency Service District #10, its agents, servants, and employees to request, receive, review and retain any and all records pertaining to my Texas driving records, criminal records held by the Texas Criminal Information Center or other state agencies, my National Criminal Information Center Records or other Federal agencies.

I am aware of the physical limitations associated with the position. Should I not be able to perform such duties, listed below is an explanation as to such limitations:

Leave blank if no limitations

The Montgomery County ESD No. 10 Fire Department Conducts Criminal Background & Driving Record Checks on all Public Safety Personnel. Please fill in the required information, answer the questions, and return this form to the fire department. This information is required for the Criminal History Investigation. MCESD 10 is an equal opportunity employer.

First Name *

Middle Name *

Last Name

Have you ever been Arrested? *

Explain

Have you ever been convicted of a Class A Misdemeanor, Felony or Sex Offense, including Indecent Exposure? *

Explain

Have you been convicted of a Class B Misdemeanor within the last 10 years? *

Explain

Have you received 3 Written Citations(tickets) within the last physical year? *

Explain

In the past three years have you had more than 3 traffic accidents? *

Explain

Has your Driver’s License ever been suspended or revoked? *

Explain *

I understand that this information is provided only for the purpose of conducting a Criminal Background & Driving Record Check and I authorize the Montgomery County Emergency Services District No. 10, to conduct the check on my behalf. I understand that falsifying information on this form or during any part of the application process may result in rejection of my application.

Signature *

Date *

Tell us about yourself and why you want to be a member of MCESD#10 *

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my application may be rejected. In addition, I authorize previous employers and references to release information as necessary to verify my qualifications and further give my permission for MCESD 10, or their agent(s), to conduct the required background checks including a police records check.

Further, Montgomery County Emergency Service District #10 may require a pre-employment physical with a physician retained by the district. Such physical may include a drug-screening test. My signature below serves as authorization to the physician to release all information relative to the Pre-employment physical and drug testing results. If such results indicate inability to perform the job applied for or drug use, I understand my application may be rejected or my employment with the district terminated.

Signature

Date

Montgomery County ESD #10 is an equal opportunity Employer and does not discriminate on the basis of sex, race, age, religion, disability, or any other legally protected classification.

Phone

Personal DataStep 1 of 10

Montgomery County Emergency Services District #10

Position Applying For: *

Instructions

Last Name *

First Name *

Middle Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Home Phone

Mobile Phone *

Email *

Social Security Number *

Are you at least 18 years old? *

Date of Birth *

Driver's licenses Number *

State *

Class *

Restrictions *

Photocopy of DL *

Drop your file here or click here to upload

EMS Certification (Level) *

TDSHS Licenses Number *

Fire Certification (Level) *

TCFP Number *

Upload a Copy of your EMS Certification

Drop your file here or click here to upload

Upload a Copy of your TCFP Certification

Drop your file here or click here to upload

Have you ever been convicted of a felony or misdemeanor? (Except a minor traffic violation) *

Explain

Work History

Do you have any other known names other than the one on this application? *

Please list all names you have gone by and the years:

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

Do you have other work history?

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

1 Do you have other work History? *

Name of Employer *

Start Date *

End Date

Leave blank if still employed

Duties *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Reason for Leaving

Please leave blank if still employed

Supervisors Name and Title *

Supervisors Phone Number *

Supervisors Email *

Emergency Contact Information

Last Name *

First Name *

Relationship *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

High School Name and Location

Did You Graduate with a Diploma? *

What Year? *

GED? If So what Year

Leave Blank if no GED

College or University:

Did you Graduate?

Major

Degree Type

How many hours do you have?

Additional Education/Vocational/Technical Training Completed:

School

Personal Skills

Please indicate briefly any job-related skills or additional information you feel may be helpful to us in considering your application:

Give three references, not relatives or former employers.

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

First Name *

Last Name *

Phone *

Occupation *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

I am aware of the physical limitations associated with the position. Should I not be able to perform such duties, listed below is an explanation as to such limitations:

Leave blank if no limitations

The Montgomery County ESD No. 10 Fire Department Conducts Criminal Background & Driving Record Checks on all Public Safety Personnel. Please fill in the required information, answer the questions, and return this form to the fire department. This information is required for the Criminal History Investigation. MCESD 10 is an equal opportunity employer.

First Name *

Middle Name *

Last Name

Have you ever been Arrested? *

Explain

Have you ever been convicted of a Class A Misdemeanor, Felony or Sex Offense, including Indecent Exposure? *

Explain

Have you been convicted of a Class B Misdemeanor within the last 10 years? *

Explain

Have you received 3 Written Citations(tickets) within the last physical year? *

Explain

In the past three years have you had more than 3 traffic accidents? *

Explain

Has your Driver’s License ever been suspended or revoked? *

Explain *

I understand that this information is provided only for the purpose of conducting a Criminal Background & Driving Record Check and I authorize the Montgomery County Emergency Services District No. 10, to conduct the check on my behalf. I understand that falsifying information on this form or during any part of the application process may result in rejection of my application.

Signature *

Date *

Tell us about yourself and why you want to be a member of MCESD#10 *

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my application may be rejected. In addition, I authorize previous employers and references to release information as necessary to verify my qualifications and further give my permission for MCESD 10, or their agent(s), to conduct the required background checks including a police records check.

Further, Montgomery County Emergency Service District #10 may require a pre-employment physical with a physician retained by the district. Such physical may include a drug-screening test. My signature below serves as authorization to the physician to release all information relative to the Pre-employment physical and drug testing results. If such results indicate inability to perform the job applied for or drug use, I understand my application may be rejected or my employment with the district terminated.

Signature

Date

Montgomery County ESD #10 is an equal opportunity Employer and does not discriminate on the basis of sex, race, age, religion, disability, or any other legally protected classification.

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