Please, print all information.

POSITION FORWHICH YOU ARE APPLYING (one position per application, please.).

Last Name_ ________________ _First_ ______________Middle__ ____________

Other Names Used or Known By______________ ____________________________________

Mailing Address__ _____________City __ _________State_ ___Zip_ ____

Present Street Address (if different from mailing address)______ _______ _________

Telephone (_ _)__ _________ ___ Work Phone (_ _)__ ______________________

Message (_ _)__ _________ Cellular (_ )___ ____________________

List all residences for the past five years:

Social Security Number: _____________ ________________________

Place of birth: (City / County / State) ___ ______________

Are you 18 years of age or older? _______Yes _______No

Do you possess a valid Arizona Driver’s License? _______Yes _______No

If yes, provide number: ____________ __________________________

Is there any reason you could not acquire an Arizona Driver’s License?

_______Yes ___ ___No

If yes, explain:_________________________________________________________

Other States you possess a Driver’s License: _________________________________

Did you graduate from high school? ______ YES _______NO

If you did not graduate, last year attended: _______________ Last year completed: _____________

Name of last high school attended: ___ ________________________________________

School address:__________ ___ ________________________________________

Do you have a GED? _______Yes _______NO

(You are required to provide a copy of either high school diploma or GED.)

List all colleges, universities and technical schools attended; most recent first.

In the space below, list any training you have acquired that might apply to the position you are seeking.

- List course or training name, description of training, who provided training, any certificate issued and

dates. (You will be required to provide proof of training or copies of certificates for all listed training.)

If presently employed, may we contact your employer? ______Yes _______No

Explain any breaks longer than 30 days. Use separate sheet of paper if necessary.

Please, provide any additional comments or information that would be of assistance in considering you for this position.

All persons applying for a position with the Hualapai Valley Fire District will be required to provide the documents listed below as applicable to the position for which they have applied. Originals and photocopies are acceptable and may be submitted with the application. However, all required documents must be on file prior to an offer of employment being made for all positions. All photocopied documents are subject to verification, and documents not provided as required will subject the applicant to termination of consideration for employment.

The following documents are required, unless otherwise noted, from all applicants regardless of position for which they have applied. Please, check mark in space provided if documents are attached to application.

The following documents are required for all applicants for emergency services personnel positions, except as noted.

______ Current Driver’s License

______ National Registry and State Emergency Medical Technician Certification.

(Administrative applicants excluded.)

_______ Advanced Life Support Certifications (if applicable)

_______ CPR Card (Administrative applicants excluded.)

_______ Professional Licenses, Registrations and Certificates

_______ Certificates of Training (Job related)

I authorize investigation of all information contained herein and specifically authorize the employers and references to give you any and all information concerning me and by doing so, release all persons, schools, companies, corporations, credit bureaus, government agencies and medical personnel from any liability for any damages that may result from furnishing same to you.

I further agree to submit to alcohol and screening tests, if requested of me, at any time prior to, or during my employment, including but not limited to urinalysis test, polygraph test, blood test, hair sampling, random or announced testing, with or without suspicion.

The District utilizes basic common sense rules, standards, guidelines and practices in its day-to-day work requirements and employment. Only some of these rules, standards, etc., are in written form. However, both the written and unwritten standards of employment and job performance are in effect. The rules, standards, guidelines and practices (often times referred to as "policies") may be amended from time to time at the discretion of the District. I agree to conform to District policies, practices, rules, regulations and guidelines. I further agree that nothing in this application is intended to create an employment contract and that any employment and the terms and benefits provided to me are not intended to and do not constitute any contractual relationship, are for no definite period of time and are terminable by myself or the District with or without notice or cause. No oral statements or representations made wither before or during employment can change or modify this non-contractual and at-will relationship.

District property and District premises include lockers, closets or other receptacles for storing personal property. The District reserves the right to inspect or search lockers, etc., in the event grounds exist for such inspection or search, or on a random basis. The grounds may include questions, suspicions or investigation of theft or missing property (District or otherwise), possession of alcoholic beverages or illicit drugs, and/or possession of dangerous weapons. I understand and agree that I am subject to the possibility of searches or inspections of my personal effects, lunch bag/box, purse, issued uniforms and other equipment, etc., in the event it is deemed necessary by District. Periodic notices of random inspections may be given.

Drug and Alcohol Testing: In order to assure a drug-free work environment, the District prohibits the use, sale, transfer, being under the influence and/or reporting to work after using or ingesting illicit drugs in accordance with department policies. Under District policy, alcohol is included within the meaning and prohibition of drugs. Successful passage of drug testing will be condition for employment and continued employment.

Sexual Harassment: Sexual Harassment is defined as any unwelcome sexual advances, requests for sexual favors, or other verbal or physical contact of a sexual nature when (1) submission of such conduct is made a job requirement or causes changes in working terms or conditions, and/or (2) it has the effect and purpose of unreasonably interfering with work performance or creating an intimidating, hostile or offensive workplace. Sexual harassment will not be tolerated and will be grounds for immediate termination.

Acquiring and maintaining, in a current status, an Arizona Driver’s License and Arizona Emergency Medical Technician Certification are conditions of employment. Failure to maintain both the driver’s license and EMT certification will result in termination of employment. [Administrative personnel excluded.]

The District has no specific residency requirement, but it is expected that employees live within or in close proximity to the District area of jurisdiction so as to be available to respond, in a reasonable amount of time, to call-back for incidents. [Administrative personnel excluded.]

In further consideration for my employment, I understand and agree that there are other forms, statements and provisions that have to be completed and agreed to, and these forms, statements and provisions are part of this application and will be included within my employment records.

I have read this Statement of Understanding and Agreement and fully understand and agree with it. By signing this application, I certify under penalty of law that the information provided anywhere in this application is true, correct and complete to the best of my knowledge and belief.

___________________________________________ ______________________

Signature Date