ESD 8 Employment Application

 

 

The following is an application for a position with the Pedernales Fire Department.

Please keep the following in mind while completing the application.

 

1.     Please read each question and all instructions carefully while completing the application.

2.     If a question does not apply to you, please enter N/A in the space.

3.     If there is not enough space to answer a question, please attach extra sheets to the last page of the application. On the top of each extra page please write the section name.

4.     Applications not properly completed will not be accepted. You will be judged in part on the neatness and completeness of this application.

5.     Use only black ink and your own handwriting. Photocopies and or typed applications will not be accepted.

6.     If you have any questions, please contact by phone (512-264-1476) or visit our web site: www.pedernalesfd.org

 

You may return this application in person or by mail:

Pedernales Fire Department

Attention: Administration

801 Bee Creek Road

Briarcliff, Texas 78669

 

A member of the Department will contact you after reviewing your application.

Thank you for your interest in the Pedernales Fire Department.

 

 

 

 

 

Please attach the following documents, in order, to the application.

 

 

□   Copy of Birth Certificate

 

□   Copy of High School Diploma or G.E.D. Certificate (for non-High School members)

 

□   Copy of College transcripts and/or diploma, if applicable towards fire service

 

□   Copy of Texas Emergency Care Attendant, Emergency Medical Technician, or Paramedic Certification, if applicable

□   Copy of Motor Vehicle insurance

 

□   Copy of Fire Certification, if applicable

 

□   Photocopy of your Driver’s License

 

□   Copy of Military Form DD-214, if applicable

 

□   Copy of Texas DPS Driving Record (prefer a five year record. If the State only releases a three year, then that would be acceptable.)

 

□   Copy of a current (within 90 days) Texas Criminal Record Check

 

 

                                                                                                        

 

 

 

 

 

 

 

 

Pedernales Fire Department Application

Date of Application: ___ ___ / ___ ___ / 20 ___

 

To start the process of becoming employed with the Pedernales Fire Department, please fill each space in this form. This form will be kept on file for one year. If qualified for an open position, you will be contacted to proceed through the hiring process.

TYPE OF EMPLOYMENT DESIRED:

□ Full-Time                            □Part-Time                            □Non-Paid / Volunteer

 

 

PERSONAL INFORMATION

Name:

 

First                                                   Middle                                                                Last

 

 

 

 

Address:

 

Number                             Street Name                                                          Apartment #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Phone:

 

Home                                                                                     Cell        

 

 

 

 

E-Mail:

 

 

 

 

 

SSN:

 

 

 

 

EMERGENCY CONTACT INFORMATION

Name:

 

First                                                   Middle                                                                Last

 

 

 

 

Address:

 

Number                             Street Name                                                          Apartment #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

          Phone:

 

Home                                                                                        Cell         

 

 

Relationship:

 

 

 

 

EMPLOYMENT INFORMATION

                   

 CURRENT EMPLOYMENT

Name:

 

 

 

 

 

 

Address:

 

Number                             Street Name                                                          Suite #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Position:

 

 

 

Supervisor:

 

 

 

Phone:

 

 

 

 

 

 

Dates of Employment:

 

 

 

 

 

 

 

 

FORMER EMPLOYMENT

Name:

 

 

 

 

 

 

Address:

 

Number                             Street Name                                                          Suite #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Position:

 

 

Supervisor:

 

 

 

Phone:

 

 

 

 

 

 

Dates of Employment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORMER EMPLOYMENT

Name:

 

 

 

 

 

 

Address:

 

Number                             Street Name                                                          Suite #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Position:

 

 

 

Supervisor:

 

 

 

Phone:

 

 

 

 

 

 

Dates of Employment:

 

 

 

 

 

 

 

 

 

FORMER EMPLOYMENT

Name:

 

 

 

 

 

 

Address:

 

Number                             Street Name                                                          Suite #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Position:

 

 

 

Supervisor:

 

 

 

Phone:

 

 

 

 

 

 

Dates of Employment:

 

 

 

 

 

 

 

 

 

 

FORMER EMPLOYMENT

Name:

 

 

 

 

 

 

Address:

 

Number                             Street Name                                                          Suite #

 

 

 

 

 

 

City                                            State                                                                Zip

 

 

 

 

Position:

 

 

 

Supervisor:

 

 

 

Phone:

 

 

 

 

 

 

Dates of Employment:

 

 

 

 

 

 

BACKGROUND INFORMATION                   

Driver’s License Number:

 

State:

 

Class:

 

Expires:

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

                   

 

□ Yes   □ No      Has your Driver’s License ever been suspended or revoked: If YES, explain the circumstances, including dates.

 

 

 

 

 

□ Yes   □ No      Have you been convicted, sentenced, placed on probation for a criminal offense or serious traffic offence? If YES, give details, including charge, location, and disposition of case.

 

 

 

 

 

 

 

□ Yes   □ No   Have you ever applied to this Department before? If YES, when?

 

 

 

 

 

 

 

 

If you need additional space, please attach a narrative on a separate page to the back of this application

 

□ Yes   □ No   Have you ever been a member of the Pedernales Fire Department or Explorer Post 8? If YES, which one and when?

 

 

 

 

 

□ Yes   □ No   Have you ever served with another fire department, EMS agency, rescue squad, or other emergency services agency before? If YES, where, when and what position(s) held?

 

 

 

 

 

 

If you need additional space, please attach a narrative on a separate page to the back of this application

 

BACKGROUND INFORMATION

High School:

Name of School

 

 

Dates Attended

□ GED

Did you graduate □ Yes   □ No     

 

 

 

 

College:

Name of School

 

 

Dates Attended

Field of Study

 

 

 

 

Did you graduate □ Yes   □ No     

 

Other:

Name of School

 

 

Dates Attended

Field of Study

 

 

 

 

 

Did you graduate □ Yes   □ No  

  

Place a check in the box next to any certifications that you currently possess:

 

Texas Commission on Fire Protection:

 

                Structure Fire Protection                              □ Basic      □ Intermediate       □ Advanced      □ Master

 

                Aircraft Fire Rescue Protection                  □ Basic      □ Intermediate       □ Advanced      □ Master

 

                Marine Fire Protection                                  □ Basic      □ Intermediate       □ Advanced      □ Master

 

                Fire Inspector                                                    □ Basic      □ Intermediate       □ Advanced      □ Master

 

                Arson Investigator                                           □ Basic      □ Intermediate       □ Advanced      □ Master

 

                Fire Service Instructor                                    □ Basic      □ Intermediate       □ Advanced      □ Master

 

□ Fire Officer 1      □ Fire Officer2       □ Haz-Mat Technician      □ Driver Operator

 

 

 

 

 

 

State Fireman’s and Fire Marshal’s Association of Texas (SFFMA):

 

                Firefighter                           □ Introductory      □ Basic       □ Intermediate      □ Advanced      □ Master

 

                Instructor                            □ Level 1                □ Level 2

 

                Fire Prevention                                 □ Level 1                □ Level 2

Specialist      

 

Arson Investigator           □ Level 1                □ Level 2

 

Fire Investigator               □ Level 1                □ Level 2

 

Driver/Operator               □ Level 1                 

 

Texas Department of State Health Services / National Registry of Emergency Medical Technicians:

 

□ CPR-AMA or Red Cross    □ ECA    □ EMT-B    □ EMT-I     □ EMT-P

 

List any other fire/EMS training, experience, college courses or certifications that you possess:

 

Military Service

               

                □ Yes   □ No   If yes, please provide the following information:

 

                Dates of Enlistment: ___________________     Year Discharged: ________________

 

               

Branch of Service: ___________________    Grand/Rank: ______________________

 

CHARACTER REFERENCES

 

                              List Four References – Other Than Family

Name:

 

 

 

 

 

 

Address:

 

Number                                                    Street Name                                                          Suite #

 

 

 

 

 

 

 

 

 

City                                                           State                                                                Zip

 

 

 

 

Relationship:

 

 

 

Phone:

 

 

             

 

 

 

 

 

 

Name:

 

 

 

 

 

 

Address:

 

Number                                                    Street Name                                                          Suite #

 

 

 

 

 

 

 

City                                                           State                                                                Zip

 

 

 

 

Relationship:

 

 

 

Phone:

 

 

             

 

 

 

 

Name:

 

 

 

 

 

 

Address:

 

Number                                                    Street Name                                                          Suite #

 

 

 

 

 

 

City                                                           State                                                                Zip

 

 

 

 

Relationship:

 

 

 

Phone:

 

 

             

 

 

 

 

  Name:

 

 

 

 

 

 

Address:

 

Number                                                    Street Name                                                          Suite #

 

 

 

 

 

 

City                                                           State                                                                Zip

 

 

 

 

Relationship:

 

 

 

Phone:

 

 

             

 

 

 

 

 

 

 

 

 CERTIFICATION OF APPLICATION

Read The Following Statements Carefully And Indicate Your Understanding And Acceptance By Signing And Dating In The Space Provided Below.

 

  1. I certify that all information provided by me in the connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, and/or omission of information shall be grounds for dismissal from the department.

 

  1. I authorize any persons or organizations referenced in this application to give the Pedernales Fire Department (Travis County ESD 8) any and all information, personal, and/ or otherwise, with regard to any subjects covered by this application, and I release all such parties from all liability from damages which may result from furnishing such information to the Pedernales Fire Department (Travis County ESD 8).

 

  1. (Applies to Firefighter Applicants) I have read and understand the attached physical requirements of a firefighter. I can physically meet the requirements of the position. I understand that if I have a pre-existing medical condition, illness, or injury that it is required by the Pedernales Fire Department (Travis County ESD 8), that I receive approval to participate in fire department activities from my personal physician.

 

  1. By accepting employment with the Pedernales Fire Department, Travis County ESD 8, I agree that Pedernales Fire Department will be my primary place of employment.

 

 

 

Signature of Applicant:

 

 

Date:

 

 

 

                      

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTOMATIC DISQUALIFIERS

Read all of the automatic disqualifiers before completing your application. Any of the following will disqualify the applicant from further consideration during any state of the process. Important: If you are not sure if any of the automatic disqualifiers pertain to you, you are required to submit a detailed letter explaining the circumstances in question.

Application Disqualifiers

 

Any of the following will disqualify the applicant from further consideration during any stage of the process.

  1. Failure to submit an application by the required notified deadline date.

 

  1. Failure to submit any subsequent required documentation or information by the required notified deadline date.

 

Criminal Disqualifiers

 

Any of the following will disqualify the applicant from further consideration during any state of the process.

 

  1. Having a conviction for, or being under indictment for, or currently charged with any felony offense (not eligible to apply).

 

  1. Having any conviction for any Class A or Class B misdemeanor offense, or currently being under indictment for, or currently charged with any Class A or B misdemeanor offenses (within the past 5 years).

 

  1. Being under indictment or charged with any Class A or Class B misdemeanor offense prior to date of submitting your application that is still pending.

 

  1. Having a conviction for driving under the influence (DWI / DUI) (within the past 5 years). Or being under indictment for, or currently charged with driving under the influence (DWI / DUI) prior to the date of submitting your application that is still pending. Or having more than one conviction for driving under the influence (DWI / DUI)

 

  1. Currently serving community supervision/ probation for any offense.

 

For the purposes of the above requirements, a person is considered convicted of an offense when an ADJUDICATION OF GUILT is entered against said person by a court of competent jurisdiction, or a PLEA OF GUILTY is entered, including situations where:

  1. The sentence is subsequently probated and the person is discharged from probation.

 

  1. Deferred adjudication is granted.

 

 

 

 

 

 

 

An excessive record of traffic convictions or negligent traffic collisions is defined as:

  1. Involvement as a driver in two or more motor vehicle accidents (within the past 3 years) where the applicant’s actions contributed to the accident in any way, whether or not citations were issued.

 

  1. Convictions for more than two moving violations within the past 3 years.

 

  1. A driver’s license suspension within the past 3 years for:

 

  • DWI
  • Failure to carry liability insurance
  • For any reason that would indicate poor driving behavior.

 

Military Disqualifiers

 

Having been discharged from military service with a DISHONORABLE discharge or a General Discharge indicating:

 

  1. Bad conduct

 

  1. Any other characterization indicating bad character

 

Drug Use Disqualifiers

 

  1. Illegal use of Marijuana in the past 3 years.

 

  1. Illegal use of any controlled substance or illegal drug, other than Marijuana, within the past 3 years.

 

  1. Having a police record of illegal drug usage or having illegally furnished any illegal or dangerous drug to another.

 

 

General Disqualifiers

 

  1. Being a member of any organization that advocates the overthrow of a governmental agency by force of violence.

 

  1. Currently, have belonged to, or been closely associated with any organization which advocates or engages in unlawful conduct directed at individuals or groups based upon the individual’s or group’s race, sex, religion, national origin, age, skin color, sexual preference, disability, or conduct otherwise commonly known as “Hate Crimes”.

 

  1. Making any false statement of fact, being deceptive by statement or omission in this application, or by any means in any part of the hiring process will result in disqualification and may be grounds for future dismissal.

RELEASE OF PERSONAL INFORMATION

I do hereby authorize a review and full disclosure of all records concerning me to any duly authorized agent of the Pedernales fire Department (Travis County ESD 8), whether the said records are of a public, private or confidential in nature.

 

The intent of this authorization is to give my consent to full and complete disclosure of the records of educational institutions, medical records, polygraph records, employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me and the records and recollections of Attorneys at Law, or of other counsel, whether representing myself or another person in any case either criminal or civil, in which I presently have or have had interest. I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly (in whole or in part), upon this release authorization will be considered in determining my suitability for service by the Pedernales Fire Department (Travis County ESD 8). I do hereby release said person(s) who provide information about me, whether supplied by a government organization or individual, from any and all liability, which may be incurred as a result of furnishing such information.

 

A photocopy or fax copy of this release form will be valid as an original thereof, even though the said photocopy or fax does not contain an original writing of my signature.

 

Signature

 

Print Name

 

Address

 

City, State,Zip

 

Phone #

 

Date of Birth

 

Social Security #

 

Driver License # & State

 

 

 

State of __________; County of ___________________________

 

Before me, the undersigned Notary Public of the State of _____________, on this day personally appeared

 

_____________________________________, (Check one) ___known to me; ___ proven to me on the

 

oath of ____________________________; or ___ proved to me through

 

 ______________________________ (description of identity card or other document) to be the person

 

whose name is subscribed to the foregoing instrument and acknowledged to me that s/he executed the

 

same for the purposes and consideration expressed and in capacity expressed therein.

 

SUBSCRIBED AND SWORN TO before the undersigned authority this _______day

 

of ____________________ 20_____ ,

 

Notary Public

Download
File name ESD 8 Employment Application 2015.pdf File Size 109 Kilobytes File Type pdf (application/pdf) Created Date Friday, 17 July 2015 Owner Tobe Cozby Modified Date Tuesday, 06 October 2015

Social Links

Burn Ban Info

Control burns are authorized.

Travis County has lifted the Burn Ban as of 01/05/2018

Please call (512) 264-1476 Ext. 260 and leave a voice mail with your information on the day you are planning to burn. If burning for the day is not advised due to possible weather issues, there will be a message stating this on the number listed above for that day.

The Village of Briarcliff has banned outdoor burning except in very strict situations.  Generally, no outdoor burning is allowed except in an enclosed container.  See BriarcliffTx.com for details.

REMEMBER – ALL burns are to be fully extinguished by 5 PM