Application for Employment

Use the form below to apply for employment as a 911 Telecommunicator with the Clearfield County Department of Emergency Management (an equal opportunity employer) . After completing this form, a representative will contact you.

PERSONAL
Last Name		Date
First Name		E-mail Address
MI
Street Address
City, State, Zip
How long have you lived at this address?
County of Residence		Home Phone
Social Security Number		Sex (M/F)
Drivers License #		State Issued
Date you would be available to start
Where are you currently employed?
If you were in the Armed Forces, when were you discharged? Month/Year
Are you over 18 years of age?
Have you ever been convicted of a traffic violation, misdemeanor, or a felony?
If Yes, indicate the date and nature of the charge, police agency, court and disposition.
EXPERIENCE
Have you ever filed an application with Clearfield County Government?
If so, when?
List any fire fighting, emergency medical or law enforcement certifications that are current.
EDUCATION
High School attended		Location (City/State)
Did you graduate or recieve a GED?		Date graduated, or recieved GED
College or University	Location (City/State)	Dates attended	Major or Degree awarded
EMPLOYMENT HISTORY
Name of employer		Start Date
Job Title		EndDate
Reason for leaving
Name of employer		Start Date
Job Title		EndDate
Reason for leaving
Name of employer		Start Date
Job Title		EndDate
Reason for leaving
REFERENCES
Please list 3 references, not related to you by blood, adoption, or marriage, that you have known for at least one year.
NAME	ADDRESS	WORK PHONE #	HOME PHONE #
Please provide any previous Fire Departments or EMS Service that you have been a member of:
DEPARTMENT	ADDRESS	DUTY OFFICER	PHONE NUMBER
ACKNOWLEDGEMENT
By signing below, I signify that I have applied for employment with Clearfield County Department of Emergency Management; that I have answered all questions truthfully and to the best of my knowledge; and that I fully understand that any intentional false statement may be grounds for dismissal from the department. Furthermore, I hereby grant to Clearfield County Department of Emergency Management permission to contact my employer, references, and any other persons or agencies that may have knowledge of me, my skills and my experience as may be deemed necessary. I also understand that I may be required to undergo a mandatory Criminal History Check, performed by the Department, at the Department's expense in order to be considered for employment.
Signature:
For security protection, please provide the SUM for the mathematical equation:

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