Employment Application

Position Applied For

Career (Specify Below)

Paid On- Call Volunteer

Student Resident Volunteer

Administration (Specify Below)

What Career position if chosen above?

What Administrative position if chosen above?

Personal Information

Full Name

Home Phone

Cell Phone

Work Phone

Home Address (City, State, Zip)

Education

List the level of your completed education and any special training, license, certifications or other skills you may have that are pertinent to the position for which you are applying, including any non-paid or volunteer work. All verifying documents must be filed with this application.

Name & Location of School

Principle Field of Study

No. of Years Completed

Degree/Certificate

Special training, license, certificates or professional memberships and affiliations:

EMT Level and Certification Number:

Employment History

This section must be completed in its entirety. List all work experience, paid or unpaid, beginning with your current or most recent employment. Include military experience as well as volunteer jobs that you wish to have considered as part of your qualifications for the position you are seeking with Woodburn Fire District. Explain all breaks in continuous employment. If more space is needed, additional pages may be added

Employer

Employment Dates (From__ To __)

Your Title

Employer Address

Supervisor Name

Supervisor Title

Supervisor Phone

Employment Status

Full Time

Part Time

Volunteer

Your Specific Job Duties

Reason for Leaving

Employer

Employment Dates (From__ To __)

Your Title

Employer Address

Supervisor Name

Supervisor Title

Supervisor Phone

Employment Status

Full Time

Part Time

Volunteer

Your Specific Job Duties

Reason for Leaving

Employer

Employment Dates (From__ To __)

Your Title

Employer Address

Supervisor Name

Supervisor Title

Supervisor Phone

Employment Status

Full Time

Part Time

Volunteer

Your Specific Job Duties

Reason for Leaving

Employer

Employment Dates (From__ To __)

Your Title

Employer Address

Supervisor Name

Supervisor Title

Supervisor Phone

Employment Status

Full Time

Part Time

Volunteer

Your Specific Job Duties

Reason for Leaving

References

Name

Phone

Years Known

Occupation

Name

Phone

Years Known

Occupation

Name

Phone

Years Known

Occupation

Name

Phone

Years Known

Occupation

Are you able to perform the primary duties of the job as outlined in the job description, with or without reasonable accommodation?

Additional Information

Please use the space provided to list any additional employers, periods of time not worked, or any other information that you believe we should know in considering your application for employment.

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION

The Woodburn Fire District is an equal opportunity employer and does not discriminate on the basis of sex, race or color, religion, marital status, national origin, handicap or veteran status.

I certify that I have answered truthfully and have not knowingly withheld any information relative to my application. I understand that any misrepresentation or material omission of this application will result in my being eliminated from further consideration. I further understand that if accepted for employment, any misrepresentation or material omission which becomes known to Woodburn Fire District will result in immediate termination of my employment or volunteer status.

I authorize all previous employers and supervisors, including all persons with whom I have worked, to give Woodburn Fire District representatives any and all information regarding me and my previous employment. I release Woodburn Fire District and all previous employers and supervisors from liability for any damages that may result from furnishing information to the Woodburn Fire District.

I understand that if selected, I will be required to provide proof of my identity and my legal right to work in the United States prior to actual employment with the Woodburn Fire District.

Signature

Date

Submissions: Please email completed applications to korrin.petersen@woodburnfire.com.

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