PLEASE NOTE THE FOLLOWING RULES THAT MUST BE ADHERED TO:

·        Must attend at least 50% of department meetings and training. 
·        Must have Firefighter II, Hazardous material operations level, Driver’s training, and pump    operations I in the first year. 
·        EMT by the end of your second year. 
·        Must be in good health.
·        Must be willing to abide by the rules of the department. 
·        Must be of excellent moral character. 
·        Must be willing to show interest and have good work ethics. 
·        Must be able to interact well with department members. 
·        Must be willing to be a “Public Servant”.

PLEASE FILL OUT COMPLETLEY:

APPLICANT RELEASE FORM:

I ​hereby apply For membership/employment with the Village of Holly Fire Department. I have been advised and am fully aware that a representative of the department with be conducting a through investigation of my background to assist in determining my suitability for this employment. I realize that, in conducting this background investigation, representatives may be making inquiries of the following personal institutions: Officials and Records Offices at schools which I have attended; Physicians and/or other persons who may have examined or treated me for any physical or other type illness or injury; Police and/or Court Records with whom I may have an arrest or conviction record; Credit Bureaus and/or firms who may have information regarding my credit history, employment history, and/or financial standing: present and previous employers; and any other persons who may be able to provide information about me which the department deems necessary. I hereby authorize and instruct any person or institution in possession of information about me to release same to the Department. I hereby waive any privileged or right which might otherwise forbid any physician, or other person who has attended me or any other school official, court, policy agency, credit bureau, employer, firm or person, from disclosing to the department any knowledge or information they have concerning me. I further consent that the Chief of the Department or his/her representative be provided with a copy of any such records concerning me which they may desire.   
I hereby give my consent to the Department or it’s designee to perform test of my blood and/or urine to determine my possible usage of prohibited substances. I recognize the right of the Department, in its sole discretion, to treat all sources as confidential, and withhold from me and/or my agent the names of such confidential sources and information obtained there from. 
Equal Employment Opportunity:  While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no effect on your application for employment.  

NOTIFICATION TO JOB APPLICANTS:

You are hereby notified and advised that you have 182 calendar days from this date to notify this company in writing of any accommodation that you would need as the result of any physical handicap that you have in order to perform the job duties of the position for which you are applying.

A handicap includes: 
(a)   A ​physical or mental condition which is the result of disease, injury, congenital condition of birth, or functional disorder if it substantially limits one or more of your major life activities and which is unrelated to your ability to perform the duties of a particular job or is unrelated to your qualifications for employment or promotion; 
(b)   A history of such a physical or mental condition; or 
(c)    The condition of being regarded as having such a physical or mental condition. 

A handicap does not include: 
(a)   A physical or mental condition caused by your current illegal use of controlled substance; or 
(b)   A physical or mental condition caused by your use of liquor if that condition prevents you from performing the duties of your job. 

A handicap is unrelated to an individual’s ability if, with or without accommodation, the handicap does not prevent the individual from performing the duties of a particular job or position. If you have a handicap, you are required to establish that you have made a written request for the accommodation within 182 days from this date, and that you could perform the duties of the position being applied for with that accommodation. This notice is given to you and a copy with your signature on it is being filed along with your employment application.  

PERSONAL INFORMATION

EDUCATION

FORMER EMPLOYERS
List last three employers, starting with last on first

References

Give the name of two persons not related to you, whom you have known at least one year

PHYSICAL RECORD

In case of emergency notify

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statement on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated at any time without prior notice.