Employment Application

STOP! Go to the job application instructions before proceeding.

You are applying for the following job:

Operations Chief – Division Chief for Operations

The application must be filled out completely - incomplete forms will not be processed!

Required fields below are marked in bold.

Applicant Information

First Name
Last Name
Mailing Address
Apt/St #
City
State
Zip Code

Home Phone
Business Phone
Cell Phone
Email Note: This address will be used for future communications.
Last 4 digits of social security #

Are you over 18 years of age? Yes No
If no, list date of birth (MM/DD/YY)
Date available to work (MM/DD/YY)

Are you a citizen of the United States or do you have a valid work permit? Yes No

Do you possess a valid driver's license? Yes No
Class
Driver's license #
State driver's license was issued in
Driver's license expiration date (MM/DD/YY)
Do you have a current commercial driver's license? Yes No

Have you volunteered for the Poudre Fire Authority before? Yes No
Supervisor's name
Job title
Start date (MM/DD/YY)
End date (MM/DD/YY)

Do you have any relatives presently working for the Poudre Fire Authority? Yes No
Name
Relationship

Are you able to perform the essential functions of the job for
which you are applying with or without reasonable accommodation? 		Yes No

Highest grade completed in school 9 10 11 12 GED 13 14 15 16 17 18

Education and/or vocational, technical or military training information relevant to the position for which you are applying:


Have you ever been convicted of or received a deferred sentence, deferred judgment, or a deferred prosecution for a petty offense, misdemeanor traffic offense (excluding civil traffic infractions) municipal code violation (excluding civil traffic infractions) misdemeanor, or felony, or been adjudicated as a juvenile for an offense that is public record?
Yes No

If yes, please list the offenses and explain the date, location, nature and facts surrounding the nature of each conviction. (If you need additional space, please include attachment with your resume.)

Employment History

Have you ever served in the United States Armed Forces? Yes No
Start date (MM/DD/YY)
End date (MM/DD/YY)
Branch of service

Employer #1

Name of employer
Business type
Telephone #
Address
City
State
Zip
Name of last supervisor
Start date (MM/DD/YY)
End date (MM/DD/YY) or 'present'
Starting wage
Wage type hourly monthly annually
Ending wage
Wage type hourly monthly annually
Job title
Duties performed:

Reason for leaving
May we contact this employer? Yes No

Employer #2

Name of employer
Business type
Telephone #
Address
City
State
Zip
Name of last supervisor
Start date (MM/DD/YY)
End date (MM/DD/YY) or 'present'
Starting wage
Wage type hourly monthly annually
Ending wage
Wage type hourly monthly annually
Job title
Duties performed:

Reason for leaving
May we contact this employer? Yes No

Employer #3

Name of employer
Business type
Telephone #
Address
City
State
Zip
Name of last supervisor
Start date (MM/DD/YY)
End date (MM/DD/YY) or 'present'
Starting wage
Wage type hourly monthly annually
Ending wage
Wage type hourly monthly annually
Job title
Duties performed:

Reason for leaving
May we contact this employer? Yes No

Employer #4

Name of employer
Business type
Telephone #
Address
City
State
Zip
Name of last supervisor
Start date (MM/DD/YY)
End date (MM/DD/YY) or 'present'
Starting wage
Wage type hourly monthly annually
Ending wage
Wage type hourly monthly annually
Job title
Duties performed:

Reason for leaving
May we contact this employer? Yes No

Employer #5

Name of employer
Business type
Telephone #
Address
City
State
Zip
Name of last supervisor
Start date (MM/DD/YY)
End date (MM/DD/YY) or 'present'
Starting wage
Wage type hourly monthly annually
Ending wage
Wage type hourly monthly annually
Job title
Duties performed:

Reason for leaving
May we contact this employer? Yes No

Education

High school name and location
Graduated? Yes No
College or University
College credits (indicate semester or quarter)
GPA
Degree
Graduated? Yes No

Special Skills

EMT/B certification? Yes No
Years of experience
Fire service experience? Yes No
Years of experience
Heavy equipment
Software applications & other certifications or experience:

Equal Employment Opportunity Compliance

To All Applicants:

The information requested below is needed in order to comply with state and federal laws and regulations. The information will be used for statistical purposes only and will not be used as part of the hiring process. Submittal of this information is strictly voluntary and refusal to provide it will not subject you to any adverse treatment.

Ethnic information
  American Indian or Alaska Native
Asian or Pacific Islander
Black/African American
Hispanic/Latino-Latina
White/Caucasian
Age
Gender Male Female
How did you first learn of this job opportunity?
  PFA website
Other website
Coloradoan
Denver Post
Friend referral
Job Line
Job fair
Professional publication
Other
Please specify

YOU ARE ALMOST COMPLETE WITH YOUR APPLICATION. PLEASE MAKE SURE YOU HAVE COMPLETED ALL PREVIOUS SECTIONS BEFORE PROCEEDING TO THE FOLLOWING SECTION, WHERE YOU WILL SUBMIT YOUR APPLICATION. PLEASE PRINT A COPY OF YOUR COMPLETE APPLICATION FOR YOUR RECORDS.

Certification and Release

I certify that all statements made in this application are true and complete. I authorize the Poudre Fire Authority to investigate all statements made as part of this application and to secure any necessary information from all prior employers, references, academic institutions, law enforcement agencies, other persons and entities, and public records. I hereby release all such persons, entities, employers, references, institutions, agencies and the PFA from any and all liability arising from their giving or receiving information about my employment history, academic credentials, qualifications, reputation, driving record, and criminal record. A photocopy of this release can be used for all purposes.

I understand that any false answers or misleading statements as well as misrepresentations by omission made by me as part of my application will be sufficient for rejection of my application or for my immediate discharge should one be discovered after I am employed.

I understand that nothing in this employment application, in the PFA's statements of personnel policies or in my communication with any PFA employee or official is intended to create an employment contract between the PFA and me. In the event that I am hired by the PFA, I understand that my continued employment will be at the mutual consent of the PFA and me. Accordingly, either the PFA or I may terminate my employment at-will at any time or without cause or notice. I understand that the at-will nature of the employment relationship can only be changed in a specific writing signed by the Policy & Personnel Administrator.

I understand that the PFA has a comprehensive Drug Free Workplace Policy for all PFA employees. In the event that I am conditionally offered a position with the PFA, I understand that I may be required to undergo a controlled substance test at an approved collection location within 48 hours of receiving the conditional offer of employment.

I hereby acknowledge that I have read, understand and agree to the preceding statement.

It is recommended you print a copy of your application prior to submitting it.

NOTE: IF YOU EXPERIENCE DIFFICULTIES SUBMITTING YOUR APPLICATION OR DO NOT RECEIVE A CONFIRMATION EMAIL, CALL 970-416-2857.