===== PAGE 1 ===== # City of Balch Springs Fire Department
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Pre - Employment Application 12500 Elam Road Balch Springs, TX, 75180 (972) 557-6040 ## AN EQUAL OPPORTUNITY, DRUG FREE WORK PLACE
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Position Applying For : Fire Fighter The City of Balch Springs Fire Department is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status, or any disability as provided in the American with Disabilities Act. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered. This application must be completed in ink or type and note that neatness is important. Resumes may be attached, however, this application MUST be completed in it's entirety. If an item doesn't apply to you, please enter "NA".
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Are you a citizen of the United States Box Yes Box No If not, do you have legal right to be employed in the U.S. Box Yes Box No Have you ever worked for the City of Balch Springs? ☐ Yes ☐ No If yes, please give name, department, and relationship Describe any course or programs which relate to this position: ===== PAGE 2 ===== ## Certifications and Licenses List any Licenses and Certifications acquired or Professional Associations to which you currently belong: Are you 18 years old or older? ☐ Yes ☐ No If no, give date of birth
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Class Texas Commission on Fire Protection Certification Level Texas Dept. of State Health Services Certification Level Name of Fire Academy & Date Completed ## Military Were you honorably discharged ☐ Yes ☐ No Service Branch Date Separated Final Rank Date Entered ## Capability / Reliability Do you have the ability, with or without reasonable accommodations, to work overtime, if overtime is required by the job for which you are appling? ☐ Yes ☐ No Would you be willing to perform all the tasks required by the job you are applying for? ☐ Yes ☐ No Will you abide by the rules and regulations of the city? ☐ Yes ☐ No Have you ever been disciplined for violating company safety rules or regulations? ☐ Yes ☐ No How many days of work or school have you missed in the last 2 years? How many times have you been late for work or school in the last 2 years? Will you be willing and able to report to work on time every day on a regular and consistent basis? ☐ Yes ☐ No Have you filed any type of fraudulent claim against any of your present or past employers? ☐ Yes ☐ No ## Special Skills Do you type? ☐ Yes ☐ No If yes, what is the words per minute?
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Have you had any computer or word processing experience or training? ☐ Yes ☐ No If yes, please describe. What languages do you speak fluently? Have you operated any machinery or special equipment? ===== PAGE 3 ===== In the last 3 years, has your driver's license been suspended, revoked, placed on probation or denied insurance? If yes, please explain. Have you had any convictions, probations or deferred adjudications for traffic citations in the last 3 years? If yes, please explain. In the last 3 years have you been convicted of Driving while Intoxicated (DWI) or Driving Under the Influence of Drugs? If yes, please 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. DO NOT REFERENCE YOUR RESUME.
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References (Give three references, not relatives or former employers)
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## Affidavit I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews, may be grounds for my immediate discharge. I hereby authorize the city of Balch Springs to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statement. I agree that, if I am employed, I will abide by all the rules and regulation of the City of Balch Springs. I understand that the taking of drug tests, alcohol tests, and other applicable tests, when given pursuant to City of Balch Springs Policy, are a condition of employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the City of Balch Springs is authorized to enter into any written or verbal employment contracts with me for any definite period of time. I also understand that my employment is "at-will" and my be terminated by myself or by the City of Balch Springs at any time for any reason or no reason at all, with or without prior notice.