Town of Brookfield Fire Department

645 Janacek Road Brookfield, WI 53045 (262) 796-3792 Fax: (262) 796-0410

APPLICATION FOR EMPLOYEMENT FIREFIGHTER/EMT

PLEASE PRINT: PERSONAL INFORMTION: Name: Last ______________________________ First _____________________ Middle ________________ Address: _________________________________ City________________________State:_______ZIP:_____________ Home Phone (_______ )____________-___________ Alt. Phone ( )____________-___________ Social Security #: __________-__________-__________Date of Birth: ________/________/________ Driver License#: ________________________ Expires: _____/_____ EMPLOYMENT HISTORY: Current Employer- Start with current or most recent first (1) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (2) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (3) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (4) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (5) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (6) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ (7) Employer name: ____________________________________________ Phone #: (_______)________-________ Address: _________________________________ City________________________State:_______ZIP:_____________ Position/Title: ____________________________ Start date: _______/______/_______ End date______/_____/______ Reason for leaving: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Supervisors name and title: _________________________________________________________________________ Do you have any reservations about the TBFD contacting any of your current or past employers? YES ☐ or NO ☐. If Yes, state your reasons: ____________________________________________________________________________ ________________________________________________________________________________________________ REFERENCES List three references that you have known for a period of five years or more. These references may not be relatives or members of the Town of Brookfield Fire Department Name: ___________________________________________ Relationship: ___________________________________ Phone #: (_______)________-__________ Alt Phone#:(_______)________-__________ Years known: ____________ Name: ___________________________________________ Relationship: ___________________________________ Phone #: (_______)________-__________ Alt Phone#:(_______)________-__________ Years known: ____________ Name: ___________________________________________ Relationship: ___________________________________ Phone #: (_______)________-__________ Alt Phone#:(_______)________-__________ Years known: ____________ Have you ever been terminated by an employer? Yes ☐ No ☐. If yes, please explain details: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ EDUCATION HIGH SCHOOL Do you have a High School diploma or GED? Yes ☐ No ☐ Name of High School: ______________________________ Address: _________________________________ City_________________________State_________zip______________ Year of Graduation: ____________________ College/Post High School education Name of High School: ________________________________ Address: ___________________________________ City_______________________State_______zip__________ Major: ___________________________________ Date of Graduation: ________________ GPA: ________________ Name of High School: _____________________________ Address: __________________________________ City_________________________State_________zip____________ Major: _______________________________ Date of Graduation: ____________________ GPA:________________ Fire or EMS training ****Submit copies of all fire and EMS related training certificates with application**** Name of school: _________________________________Major: ___________________________________ Graduation Date: ________/________/________ Name of school: _________________________________Major: ___________________________________ Graduation Date: ________/________/________ Name of school: _____________________________________ State of WI Level I Firefighter Yes ☐ NO ☐ State Certification #: ________________________ Graduation Date: ________/________/________ Name of school: _____________________________________ State of WI Level II Firefighter Yes ☐ NO ☐ State Certification #: ________________________ Graduation Date: ________/________/________ Name of school: _____________________________________ State of WI EMT-B Yes ☐ NO ☐ State Certification #: ________________________ Graduation Date: ________/________/________ Name of school: _____________________________________ State of WI EMT-I or P Yes ☐ NO ☐ State Certification #: ________________________ Graduation Date: ________/________/________ MILITARY SEVICE Have you served in the United States Military? _____________ If so, what branch ______________________________ Length of service: ____________ years Type of discharge: _______________________________________________ Are you currently in the reserves _____________ If so, what branch__________________________________________ CRIMINIAL HISTORY PLEASE LIST ALL CITATIONS FOR THE PAST 10 YEARS Date of citation: ________/________/________ Type of citation: ____________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Date of citation: ________/________/________ Type of citation: ____________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Date of citation: ________/________/________ Type of citation: ____________________________________________ ______________________________________________________________________________________________ Date of citation: ________/________/________ Type of citation: ____________________________________________ _______________________________________________________________________________________________ Date of citation: ________/________/________ Type of citation: ____________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Date of citation: ________/________/________ Type of citation: ____________________________________________ _______________________________________________________________________________________________ Have you ever been convicted of a felony? YES ☐ NO ☐ If yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Have you ever been at fault in a motor vehicle accident? YES ☐ NO ☐ If yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Do you use illegal drugs? YES ☐ NO ☐ If yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Is there any additional information that you would like to include at this time? __________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ *****Attach separate sheet for any additional information****** Medical History Do you have any physical limitations that would interfere with your ability to perform the duties of a Firefighter/EMT for the Town of Brookfield Fire Department? YES ☐ NO ☐ If yes, please explain: _______________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Do you have any allergies such as latex, medications, etc? YES ☐ NO ☐ If yes, please explain: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ STATEMENT OF TRUTH I, ___________________________________have completed this application for employment truthfully, completely, and to the best of my knowledge. I have not falsified and information submitted within this application and understand that I will be removed from the hiring process and lose all rights to be hired by the Town of Brookfield Fire Department if do submit or make any statement that are found to be untrue. Print Full Name: ________________________________________ Signature Full Name: _____________________________________ Date: ________/________/________

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