LAFAYETTE TOWNSHIP FIRE PROTECTION DISTRICT 4002 SCOTTSVILLE ROAD FLOYDS KNOBS, IN 47119 Phone: (812) 923-8003 FAX: (812) 923-1961 Web: www.ltvfd.org We are pleased you have decided to apply to become a Firefighter with the Lafayette Township Fire Protection District. Please complete the attached application, which is the first step in the process you will undergo to become an active Firefighter. After you have completed the application, mail or deliver it to us. Some documents you will need to attach to your completed application are outlined on the Eligibility List Announcement, including your current driver’s license and any medical, trade, or professional certificates and/or licenses you currently possess. Since you are applying for a paid position, you also will be required to show us proof that you are eligible to work in the United States. The attached Firefighter Position Description and the information about the Americans with Disabilities Act are yours to keep. We look forward to hearing from you soon! LAFAYETTE TOWNSHIP FIRE PROTECTION DISTRICT 4002 SCOTTSVILLE ROAD FLOYDS KNOBS, IN 47119 Phone: (812) 923-8003 FAX: (812) 923-1961 Web: www.ltvfd.org APPLICATION FOR FIREFIGHTER POSITION PRINT LEGIBLY, IN INK. Answer each item completely and accurately. Incomplete answers may disqualify you or may cause delays in the processing of your application. FALSE answers may lead to rejection and/or dismissal. Please write the letters “NA” (Not Applicable) in the sections which do not apply to you. Attach additional pages if needed. The Firefighter Position Description accompanying this application describes “Essential Functions,” “Reasonable Accommodations,” “Minimum Qualification Requirements,” and “Minimum Standards to Maintain Position” for a Firefighter in this fire protection district. Today’s Date: Name: (last) (first) (middle) (Jr./Sr.) Current Home Address (number, street, city, state, zip code): 4. Home Phone: Cell: Pager: List all former addresses you have had during the past five years, beginning with the most recent. 6. Are you at least 21 years of age? Yes No If not, state your age: 7. Social Security Number: 8. Do you possess a valid driver’s license? Yes No State _______ Expires _________ Class _____ 9. List any medical, trade, or professional certificates and/or licenses you possess. (ATTACH COPIES OF ALL) Name of Certificate or License: Cert./License No.: Name of Licensing Agency: Address of Licensing Agency: ================================================================================= Name of Certificate or License: Cert./License No.: Name of Licensing Agency: Address of Licensing Agency: ================================================================================= Name of Certificate or License: Cert./License No.: Name of Licensing Agency: Address of Licensing Agency: Place a checkmark next to each of the following for which you hold a current certificate or license: Basic Firefighter Driver/Operator Pumper IFSAC or Indiana Firefighter 1 IFSAC or Indiana Firefighter 2 IFSAC or Indiana Instructor 1 IFSAC or Indiana Instructor 2/3 IFSAC or Indiana Fire Officer 1 IFSAC or Indiana Fire Officer 2 IFSAC or Indiana Fire Officer 3 IFSAC Fire Officer 4 IFSAC or Indiana Inspector 1 IFSAC or Indiana Inspector 2 IFSAC or Indiana Safety Officer Indiana First Responder Indiana EMT-B Indiana EMT-A Indiana EMT-I Indiana EMT-P Haz-Mat: Swift water: Awareness Awareness Operations Operations Technician Technician Rope Rescue Technician Instructor Other please list: List firefighting equipment, machinery, and office equipment (including computers), you are able to operate: 12. Have you ever served in the military? Yes No If yes, complete the following. Service Dates: from to Branch: Rank at time of discharge: (ATTACH COPY OF FORM DD-214) Employment Experience: Begin with your most recent job and describe in detail each specific job you have held during the last fifteen 15 years. Periods of unemployment also should be noted. Leave no gaps in time sequence. Be sure to list all applicable experience that qualifies you for the position sought. Attach additional forms if needed to complete your employment history. You may exclude organizations that indicate age, color, religion, gender, national origin, handicap, or any other protected status. Employer: __________________________ Describe your duties: ________________________________________ Address: ___________________________ _________________________________________________________ ___________________________________ _________________________________________________________ ___________________________________ _________________________________________________________ Type of Business: ____________________ _________________________________________________________ ___________________________________ _________________________________________________________ Your Position: _______________________ _________________________________________________________ Dates: _____________ to _____________ _________________________________________________________ Wages: Start __________ End __________ _________________________________________________________ Supervisor’s Name: __________________ _________________________________________________________ Supervisor’s Title: ____________________ _________________________________________________________ Reason for Leaving: __________________ _________________________________________________________ ___________________________________ _________________________________________________________ Employer: __________________________ Describe your duties: ________________________________________ Address: ___________________________ _________________________________________________________ ___________________________________ _________________________________________________________ ___________________________________ _________________________________________________________ Type of Business: ____________________ _________________________________________________________ ___________________________________ _________________________________________________________ Your Position: _______________________ _________________________________________________________ Dates: _____________ to _____________ _________________________________________________________ Wages: Start __________ End __________ _________________________________________________________ Supervisor’s Name: __________________ _________________________________________________________ Supervisor’s Title: ____________________ _________________________________________________________ Reason for Leaving: __________________ _________________________________________________________ ___________________________________ _________________________________________________________ Employer: __________________________ Describe your duties: ________________________________________ Address: ___________________________ _________________________________________________________ ___________________________________ _________________________________________________________ ___________________________________ _________________________________________________________ Type of Business: ____________________ _________________________________________________________ ___________________________________ _________________________________________________________ Your Position: _______________________ _________________________________________________________ Dates: _____________ to _____________ _________________________________________________________ Wages: Start __________ End __________ _________________________________________________________ Supervisor’s Name: __________________ _________________________________________________________ Supervisor’s Title: ____________________ _________________________________________________________ Reason for Leaving: __________________ _________________________________________________________ ___________________________________ _________________________________________________________ Employer: __________________________ Describe your duties: ________________________________________ Address: ___________________________ _________________________________________________________ ___________________________________ _________________________________________________________ ___________________________________ _________________________________________________________ Type of Business: ____________________ _________________________________________________________ ___________________________________ _________________________________________________________ Your Position: _______________________ _________________________________________________________ Dates: _____________ to _____________ _________________________________________________________ Wages: Start __________ End __________ _________________________________________________________ Supervisor’s Name: __________________ _________________________________________________________ Supervisor’s Title: ____________________ _________________________________________________________ Reason for Leaving: __________________ _________________________________________________________ ___________________________________ _________________________________________________________ 14. Have you ever been convicted of a crime? Yes No If yes, complete the following. Charge Location (city/state) Date Disposition of Charge 15. Are there any felony charges pending against you? Yes No 16. How did you learn about this position? Please check all that apply. Firefighter Newspaper Ad Personal Contact Mailing Posting Radio/TV Ad Other I certify that the information given in this Application is correct and compete to the best of my knowledge. I am aware that should an investigation at any time show falsification, I may be excluded from consideration for membership; or if I am already a member, my membership may be terminated and/or I may be disqualified from consideration for future membership. Applicant’s Signature Date LAFAYETTE TOWNSHIP FIRE PROTECTION DISTRICT 4002 SCOTTSVILLE ROAD FLOYDS KNOBS, IN 47119 Phone: (812) 923-8003 FAX: (812) 923-1961 Web: www.ltvfd.org AUTHORIZATION FOR RELEASE OF RECORDS I, (print your name here) , hereby authorize the Lafayette Township Fire Protection District to request any law enforcement agency, former employer, to release all information (including but not limited to traffic, arrest/conviction) to the Lafayette Township Fire Protection District or its representative, which may be sought in connection with my application for the position of Firefighter with the Lafayette Township Fire Protection District. Social Security Number: Date of Birth: Additional descriptive information may be provided to identify me if necessary or requested. A photocopy of this Release shall be considered as effective and binding as the original hand-executed copy. Signature of Applicant Date (please sign this in the presence of a witness) Signature of Witness Request For Criminal Records The Lafayette Township Fire Protection District has made a request for any criminal record conviction found in the file of the criminal history record information system regarding the person identified herein. This information shall be released to the Lafayette Township Fire Protection District P.O. Box 51 Floyds Knobs, IN 47119. Acknowledgement By Applicant I have applied for employment or a volunteer position with the Lafayette Township Fire Protection District. I am requesting that the Indiana State Police provide the employer with any record of conviction found in the file of the criminal history record information system. I know that I have the right to inspect my criminal history record and to request correction of any inaccurate information. If I do not exercise that right, I agree to hold harmless the Indiana State Police and the Lafayette Township Fire Protection District and any employee(s) from either agency from any claim for damages arising form the dissemination of inaccurate information. Applicant Information (Please Print) Name: Last First Middle Maiden Address: Street City State Zip Sex: Race: Date of Birth: Social Security #: Signature Date Witness Date LAFAYETTE TOWNSHIP FIRE PROTECTION DISTRICT FIREFIGHTER POSITION DESCRIPTION Essential Functions: The most important and indispensable duties required of a Firefighter with the Lafayette Township Fire Protection District relate to fire suppression and rescue procedures, including the following functions. 1) Safety: A Firefighter must . . . a) Know the dangerous building conditions created by fire. b) Be able to act in a fire situation or hostile environment. c) Be able to use safety procedures in emergency operations in relation to i) Protective equipment ii) Teamwork iii) Portable tools and equipment iv) Riding on apparatus v) Hazardous materials incidents d) Not pose a direct threat or significant risk to the health or safety of other Firefighters or the public. 2) Emergency Medical Care and Rescue: A Firefighter must be able to examine a victim to identify symptoms of life-threatening injuries, to search for victims in smoke-filled buildings or other hostile environments, and remove injured persons from the immediate hazard. A Firefighter also must be able to respond to emergency medical care calls as assigned for assistance to sick or injured people and treat them according to guidelines. 3) Fire Equipment: A Firefighter must be able to use fire equipment such as nozzles and hose appliances carried on a pumper, advance dry hose lines, connect a fire hose to a hydrant, couple and uncouple fire hose, work from a ladder with a charged attack line, carry hose into buildings, and replace a burst section of hose, all in an emergency situation. 4) Self-Contained Breathing Apparatus: A Firefighter must know the various hazardous respiratory environments encountered in firefighting, and be able to use self-contained breathing apparatus in an emergency situation. 5) Forcible Entry and Ventilation: A Firefighter must be able to use manual forcible entry tools, know the advantages and effects of ventilation, and be able to ventilate a fire. 6) Ladders: A Firefighter must be able to carry, raise and climb ground and aerial ladders, carry firefighting tools and equipment while ascending and descending, and bring injured persons down the ladders. Page 1 of 2 Reasonable Accommodations: The Lafayette Township Fire Protection District will make reasonable accommodations for any individual with disabilities unless the accommodation would present a direct threat or significant risk to the health or safety of other Firefighters or the public, or would impose an undue hardship on the operation of the Lafayette Township Fire Protection District. Minimum Qualification Requirements: A Firefighter with the Lafayette Township Fire Protection District must have the following Minimum Qualifications. 1) A Firefighter must have a high school diploma or state recognized equivalent. 2) A Firefighter must be at least twenty-one (21) years of age. 3) A Firefighter must have completed an “Application for Firefighter Position” for the Lafayette Township Fire Protection District. 4) The Lafayette Township Fire Protection District must complete an investigation of the applicant’s personal and work history to determine if any matters exist that would affect the Firefighter in the performance of his/her duties and responsibilities as a Firefighter. 5) Must possess a valid Drivers’ License. 6) One (1) year as a Firefighter 7) Current NIMS Certifications 8) Must obtain Hazardous Materials Operations Level within one (1) year of employment. 9) Must obtain Emergency Medical Technician – Basic within one year of employment. Minimum Standards to Maintain Position: A Firefighter with the Lafayette Township Fire Protection District must maintain the following Minimum Standards. 1) Complete a one-year (1-year) probation period with the Lafayette Township Fire Protection District. 2) Obtain IFSAC Firefighter 1 and 2 within one (1) year of employment. 3) Maintain First Responder, EMT, and Haz-Mat Operations licensure/certification throughout his/her employment with Lafayette Township Fire Protection District. Page 2 of 2 LAFAYETTE TOWNSHIP FIRE PROTECTION DISTRICT GRIEVANCE PROCEDURES RELATED TO AMERICANS WITH DISABILITIES ACT The Lafayette Township Fire Protection District adopts the following grievance procedures to provide a prompt and equitable resolution of complaints alleging any action under Title II of the Americans with Disabilities Act. 1. All complaints regarding access or alleged discrimination should be submitted in writing to the Safety Officer of the Lafayette Township Fire Protection District who shall be the Americans with Disabilities Act (“ADA”) Coordinator for resolution. A record of the complaint and action taken will be maintained. A decision by the ADA Coordinator will be rendered within fifteen (15) working days. 2. If the complaint cannot be resolved to the satisfaction of the complainant by the ADA Coordinator, it will be forwarded to an ADA compliance committee composed of representatives from the Board of Trustees of the Lafayette Township Fire Protection District, the disabled community, business or non-profit sectors, and education and health/medical professions. The committee will be appointed by the Chairman of the Board of Trustees. 3. The ADA compliance committee shall be charged with establishing ground rules or procedures for hearing complaints, requests or suggestions from disabled persons regarding access to and participation in public facilities, services, activities and functions related to the Lafayette Township Fire Protection District. Further, the committee should be directed to hear such complaints in public, after adequate public notice is given, in an unbiased, objective manner. The committee should issue a written decision within thirty (30) days of a hearing. All proceedings of the committee should be recorded and maintained for five (5) years. 4. If the complaint cannot be resolved to the complainant’s satisfaction by the committee, the complaint will be heard by the Board of Trustees of the Lafayette Township Fire Protection District. An open, public meeting of the Board of Trustees will precede the vote. A determination must be made within thirty (30) days of the hearing. The decision of the Board of Trustees is final. 5. A record of action taken on each request or complaint must be maintained as a part of the records or minutes at each level of the grievance process. 6. The individual’s right to prompt and equitable resolution of the complaint must not be impaired by his/her pursuit of other remedies, such as the filing of a complaint with the U.S. Department of Justice or any other appropriate federal agency. Furthermore, the filing of a lawsuit in state or federal district court could occur at any time. The use of this grievance procedure is not a prerequisite to the pursuit of other remedies. |