Bristol Fire and Rescue Membership/Employment Application Applicant Information Full Name: Date: Last First M.I. Address: Street Address Apartment/Unit # City State ZIP Code Mailing Address If different Mailing Address Home Phone: Cell Phone: Email: Date Available: Position Applied for: YES NO Have you worked under a different name? If yes, what name? ___________________________________ YES NO YES NO Are you 18 years or older? Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? How long will your Visa allow you to work in the US? Not YES NO Applicable Will you now, or in the future, require sponsorship for United States employment Visa status? YES NO Have you ever worked for this company? If yes, when? YES NO Have you ever been convicted of a felony or misdemeanor (except minor traffic violations)? Convictions that were completely expunged or were reversed on appeal are not considered convictions for purposes of this question and should not be included or considered in answering this question. A conviction has been “completely expunged” only if no one, including law enforcement, can be permitted access to the record even by court order under the State of Federal Law which was the basis of the expungement. Convictions against a person as a juvenile or youthful offender, youthful offender adjudgements and/or of juvenile delinquency are not considered convictions for purposes of this question and should not be included or considered in answering this question. If yes, explain: Please explain in detail the facts relative to the disclosable conviction(s). An answer of “yes” will not disqualify any applicant for consideration for a job; rather, such information is only relevant in determining whether the conviction is directly related to the job for which you are applying, and will be only one of the factors considered in the employment decision and evaluated in terms of the nature, severity, and the date of offense. 1  Education High School: Address: YES NO From: To: Did you graduate? Diploma:: College: Address: YES NO From: To: Did you graduate? Degree: Other: Address: YES NO From: To: Did you graduate? Degree: Please list any special skills, trainings, or certifications pertaining to the fire and EMS service that you may have. Please indicate skill level: 1. 2. 3. 4. 5. 6. Additional Comment: References Please list three professional references (excluding relatives) Full Name: Relationship: Company: Phone: Address: Full Name: Relationship: Company: Phone: Address: Full Name: Relationship: Company: Phone: Address: 2  Previous Employment Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Company: Phone: Address: Supervisor: Job Title: Responsibilities: From: To: Reason for Leaving: YES NO May we contact your previous supervisor for a reference? Military Service Branch: From: To: Rank at Discharge: Type of Discharge: If other than honorable, explain: 3  How did you hear of this position? Referral Advertisement Other Who? _______________ ____________________ ___________________ Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any omissions or false or misleading information in my application or interview or other aspects of the hiring process may result in my disqualification from further consideration for employment, or, if discovered after hire; such information may be grounds for the immediate termination of my employment. I understand that membership and continued membership with Bristol Fire and Rescue is contingent upon satisfactory consumer reports and criminal background checks. I authorize the Fire Chief of Bristol Fire and Rescue as well as the Human Resources Department of the Town of Bristol to investigate, verify and discuss all information set forth in my employment application, by contacting my prior employers; colleagues; educational institutions; and other references set forth above, and by any and all other means authorized or permitted by law. I authorize any entity or person named in this application to provide the Fire Chief and the Town of Bristol with information that may be requested to arrive at an employment decision. I release and agree to hold harmless the Town of Bristol and its subsidiaries and affiliates, and each and all of their respective employees, agents and representatives, from any and all claims, liability or damages that may arise as a result of taking any actions described herein. In addition, I release and agree to hold harmless any and all individuals and entities that provide any information concerning me, whether orally or in writing, in response to a request for such information from the Town of Bristol. If I am accepted into membership of the Bristol Fire and Rescue, I promise to comply with all policies, rules and regulations implemented by Bristol Fire and Rescue as set forth in the bylaws of Bristol Fire and Rescue. By signing below, I hereby acknowledge that I have read, agree to and accept the above terns and statements. Signature: Date: Equal Employment Opportunity Policy It is the policy and practice of Bristol Fire & Rescue to abide by all anti-discrimination laws provided for by federal, state, and local statutes and regulations. It is also the policy and practice of Bristol Fire & rescue to provide and promote equal employment opportunities for all applicants and employees. It is also the policy and practice of the Bristol Fire & Rescue to recruit, hire, train, promote, compensate, and administer all employment practices without regard to race, color, sex or sexual orientation, age, religion, veteran status, liability for military service, whistleblower status, gender identity and/or expression, atypical cellular or blood trait, genetic information (including the refusal to submit to genetic testing or make available the results of a genetic test or on the basis that an individual received a genetic test or genetic counseling), national origin, ancestry, nationality, creed, citizenship, alienage, marital or domestic partnership or civil union status, mental or physical disability, or any other characteristic protected under federal, state, or local law and to affirmatively seek to advance the principles of equal employment opportunity. Furthermore, Bristol Fire & Rescue is committed to complying with the Americans with Disabilities Act and similar state laws. If you believe that you need a reasonable accommodation in order to apply for employment or to complete an application for employment due to the fact that you may have a disability, please notify the Town of Bristol within three (3) days of your application of your specific needs for a reasonable accommodation so that we can assist you where appropriate. If an applicant requests an accommodation for purposes of completing the job application process, the Town of Bristol reserves the right to require the application to furnish documentation from an appropriate professional (for example, a doctor, rehabilitation counselor, etc.) confirming that the applicant has a disability or the functional limitations for which a reasonable accommodation is requested. 4