Fire & EMS Application

Jefferson Township Fire/EMS
Online Application for Employment

We are an Equal Opportunity Employer. Applicants are considered for all positions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, age, disability, marital or veteran status, or any other legally protected status in accordance with applicable federal, state, and local laws.

Section 1: Position Information

Date(Required)

Position Applied For(Required)

Section 2: Personal Information

Name(Required)

Prefix First Middle Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Enter Email Confirm Email

Social Security Number(Required)

Section 3: Employment Eligibility & Availability

Have you ever been employed by Jefferson Township?(Required)

Yes

Previous / Current Position(Required)

Date Of Employment

Are you related to any current employee(s)?(Required)

Yes

Name(Required)

Relation(Required)

Are you willing to work overtime?(Required)

Yes

Are you currently employed?(Required)

Yes

May we contact your current employer?(Required)

Yes

When can you start work?(Required)

Do you have a valid Ohio driver's license?(Required)

Yes

Are you legally authorized to work in the U.S.?(Required)

Yes

Can you provide proof of work eligibility?(Required)

Yes

Are you physically able to perform job duties with or without accommodation?(Required)

Yes

Have you ever been discharged from a job?(Required)

Yes

Explanation of Discharge(Required)

Section 4: Education

High School / GED

Name(Required)

Location(Required)

Years Completed(Required)

Diploma Received(Required)

College / University / Technical Schools

Name(Required)

Location(Required)

Course of Study(Required)

Years Completed(Required)

Diploma Received(Required)

Honors Received

List More?

List Another School

Name(Required)

Location(Required)

Course of Study(Required)

Years Completed(Required)

Diploma Received(Required)

Honors Received

Section 5: Certifications & Training

Check All That Apply

EMT Certification

Paramedic Certification

Firefighter II Certification

Other Firefighter Level

HazMat Certification

Other Specialized Training

EMT Certification

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

Paramedic Certification

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

Firefighter II Certification

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

Other Firefighter Level

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

HazMat Certification

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

Other Specialized Training

Year Completed(Required)

Certification Number(Required)

Institution/Location(Required)

Section 6: Skills

Describe any specialized training or qualifications you have relating to the position applied for.(Required)

Describe any computer skills you possess, including software and hardware experience .(Required)

Foreign Languages (Including ASL)

Language:

Proficiency Type

Speak

Read

Write

Proficiency Level

Native

Fluent

Good

Fair

Language:

Proficiency Type

Speak

Read

Write

Proficiency Level

Native

Fluent

Good

Fair

Section 7: Employment History

Employer #1

Employer Name(Required)

First Last

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer Phone(Required)

Starting Date(Required)

Ending Date

Job Title(Required)

Supervisor Name(Required)

First Last

Starting Salary(Required)

Ending Salary

Job Duties(Required)

Reason for Leaving

May we contact?(Required)

Yes

List Another?

List Another Employer

Employer #2

Employer Name(Required)

First Last

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer Phone(Required)

Starting Date(Required)

Ending Date

Job Title(Required)

Supervisor Name(Required)

First Last

Starting Salary(Required)

Ending Salary

Job Duties(Required)

Reason for Leaving

May we contact?(Required)

Yes

List Another?

List A Third Employer

Employer #3

Employer Name(Required)

First Last

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer Phone(Required)

Starting Date(Required)

Ending Date

Job Title(Required)

Supervisor Name(Required)

First Last

Starting Salary(Required)

Ending Salary

Job Duties(Required)

Reason for Leaving

May we contact?(Required)

Yes

Section 8: References (At least 3 required)

Reference #1

Reference Name(Required)

First Last

Reference Address

Street Address Address Line 2 City State ZIP Code

Reference Phone(Required)

Relationship (Not a relative or previous employer)(Required)

Reference #2

Reference Name(Required)

First Last

Reference Address

Street Address Address Line 2 City State ZIP Code

Reference Phone(Required)

Relationship (Not a relative or previous employer)(Required)

Reference #3

Reference Name(Required)

First Last

Reference Address

Street Address Address Line 2 City State ZIP Code

Reference Phone(Required)

Relationship (Not a relative or previous employer)(Required)

Section 9: Additional Information

Other Qualifications (skills, licenses, achievements)

Additional Comments

Section 10: Required Files

After review, we will request to have the following documents prepared for submission:

Highest Fire Certification
Highest EMS Certification
CPR Card
Ohio Driver’s License
Proof of Auto Insurance
Social Security Card

Section 11: Ohio BCI Background Check Requirement

You are required to obtain a State of Ohio BCI Background Check from Fayette County Sheriff’s Office.

Contact: Fayette County Sheriff’s Office

Address: 1500 Robinson Road SE, Washington Court House, OH 43160

Phone: 740-335-6170 (call to schedule an appointment)

Important: Fees are the applicant's responsibility. Online background checks are not accepted.

Please allow 10–20 days for background check processing.

Section 12: Applicant Declaration

I certify that all information is true and complete.
I authorize investigation of all statements.
I understand false information may disqualify me or result in termination.
I agree to abide by all rules and regulations if employed.
I understand physical and drug testing may be required.
I understand this application is valid for 1 year.

Authorization and Release

READ CAREFULLY BEFORE SIGNING. IF NOT UNDERSTOOD, SEEK COMPETENT LEGAL ADVICE.

In connection with my application for employment, I expressly authorize the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public and private agencies, licensing authorities and educational institutions to otherwise verify the accuracy of all information provided by me in the application and interview process. Should I be the final applicant, I expressly authorize the employer, its representatives, employees or agents to contact and obtain a criminal background report pertaining to criminal conviction and sexual offender records.

I understand that misrepresentation or omission in the application and interview process may be cause for rejection or may be cause for subsequent dismissal if I am hired.

I voluntarily and knowingly authorize any former employer, person, firm, corporation, school or government agency, its officers, employees and agents, to release any and all information concerning my former employment to you or your agents. I understand that the employment information may include, but is not necessarily limited to, performance evaluation and reports, job descriptions, disciplinary reports, letters of reprimand, and opinions regarding my suitability for employment.

I voluntarily and knowingly fully release and discharge, absolve, indemnify and hold harmless you, your agents, employees and any former employer, person, firm, corporation, school or government agency, its officers, employees and agents, from any and all claims, liability, demands, causes of action, damages, or costs, including attorney's fees, present or future, whether known or unknown, anticipated or unanticipated, arising from or incident to the disclosure or release of any such information to you, or your agents.

I hereby authorize you to procure reports as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to procure reports at any time during my employment period.

Applicant Signature(Required)

Prefix First Last

Application Date

Section 13: Driver Background Check Authorization

All data submitted through this form is protected and handled in accordance with applicable Ohio public records and data privacy laws.