Recruit Application Fire Academy

Transcription

1 Recruit Application Fire Academy Applicant Name: Street Address: Daytime telephone: Desired Class: Fire Fighter I & II Notification of Social Security Number Collection and Usage In compliance with FL Statute , this document serves to notify you of the purpose for the collection and usage of your Social Security number. Tallahassee Community College collects and uses your social security number only in performance of the College s duties and responsibilities. To protect your identity TCC will secure your social security number from unauthorized access, never release your social security number to unauthorized parties, and assign you a unique student or employee identification number. This unique identification number is used for all associated employment and educational purposes at TCC. Date Received: FOR ACADEMY USE ONLY Oral Board Date: Class Start Date: Oral Board Recommendation: Y N Application Fee Received: Y N

2 FIRE ACADEMY TALLAHASSEE COMMUNITY COLLEGE DECLARATION FORM All statements and information given in this application are true to the best of my knowledge. In the event that I am admitted to the Academy, I understand that any information found to be omitted or incorrect on any portion of my application may constitute grounds for dismissal. By my signature below, I hereby authorize the Tallahassee Community College to conduct such investigations as are necessary to determine the accuracy and completeness of this application. Signature Date Before me personally appeared Signed the above document on (Name) (Date), who in my presence,. The applicant produced the following identification personally known by me. (Type of Identification) or is Notary s Name: Notary s Signature: Date: SEAL

3 ACADEMY FINANCIAL AID AND REFUND DISCLOSURE FORM As an applicant for a recruit training program at the Tallahassee Community College (College) Fire Academy you are applying for a program of study made up of individual courses offered to the cohort of students that begin the program together. Each of those courses must be successfully completed in order to continue in the program and the program in its entirety must be successfully completed in order to be eligible to take the State Officer Certification Exam prior to employment in Florida as a Fire Fighter. No students may be added to the program by enrolling after the program begins. (Fire Fighter I and Fire Fighter II is two separate programs) Therefore, no refunds for courses enrolled in but not taken or successfully completed as part of the entire program will be made after the first five days of the program. If you are a student who receives Title IV student financial aid (Federal Pell Grants, Federal SEOG, Federal Stafford Loans or PLUS Loans) and you withdraw, are dismissed, or your classes are canceled for any reason, your financial aid will be reviewed by the College under the Federal Return to Title IV policy, as required by the Federal Government. Students who withdraw or are dismissed and who receive Title IV Federal financial aid may owe the Federal Government, TCC, or both, money based on the determination of the Federal review. These funds would be in addition to any tuition you may owe. If you have any questions about your potential financial liability, you are directed to contact the College s Financial Aid Office for assistance before enrolling in this program. Your signature below acknowledges you have read and understand your financial obligations as described above. Date Applicant Signature

4 INSTRUCTIONS FOR FILLING OUT FIREFIGHTER RECRUIT APPLICATION You are about to take the most important step toward an exciting and rewarding career anyone can take. The following pointers will help you succeed in gaining acceptance at the Fire Academy. When filling out this application, please type or print legibly in black ink. Fill out the application in its entirety. Any omitted information may disqualify you from acceptance to the Academy. If you have questions about whether to include any information requested, contact Academy staff for guidance. Remove the physical form from this application packet and keep it until you are notified whether or not you have been accepted. If accepted to the Academy, you will be instructed to take the physical form to a licensed physician for a complete physical, including a 12 lead EKG (in accordance with NFPA 1582). When turning in your application, make sure that all necessary documentation is attached with the application. (See next page for checklist) Please fill out the application carefully and recheck it for any omissions or mistakes. Incomplete applications are not acceptable and shall not be processed. If any of the necessary documentation that is required to be turned in with the application is unavailable at the time you submit your application, please make note of it on the comments form, stating when you expect to obtain the information and turn it in.

5 APPLICATION CHECKLIST 1. The following items must accompany your application at the time you submit it. Declaration Form (included in this packet) 7-year Driving History (obtained from DHSMV) Copy of Drivers License Copy of High School Diploma/GED or College Degree, if earned Copy of Birth Certificate Copy of Social Security Card $50.00Application fee Completed Background Investigation Form 2. Please note that if your court record indicates you have been arrested for a drug offense you may be required to submit to a drug test, at your expense, at a designated medical facility prior to admission into the Academy. 3. Return your application with the documentation required to the Academy at the following address: FIRE ACADEMY ADMISSIONS OFFICE 75 COLLEGE DRIVE ATT: FIRE COORDINATOR SUITE 203 HAVANA, FL 32333

6 FIRE ACADEMY/TALLAHASSEE COMMUNITY COLLEGE INFORMATION RELEASE FORM Applicant: Date of Birth: Social Security #: To Whom It May Concern: I am an applicant for admission to the Fire Academy in a training program. In order for the Fire Academy (Academy) to conduct a comprehensive investigation prior to my admission it may be necessary for certain information that might otherwise be confidential to be released to them. Further, I hereby acknowledge that if I am accepted for admission it may also become necessary for the Academy to conduct an investigation of me during my Academy class. This release authorizes disclosure of records including, but not limited to, education records, medical records, employment records and credit records to representatives of the Academy at any time prior to the scheduled graduation date of my class from the Academy. By copy of this form, I hereby authorize the release (including duplication of records) to representatives of the Fire Academy of any and all records concerning me you may hold. Signature of Applicant Date

7 FIRE ACADEMY APPLICATION FOR FIREFIGHTER RECRUIT POSITION Please print neatly in black ink or type. PERSONAL HISTORY 1. Full Name: Last First Middle 2. Have you ever had your name changed? Yes No If you answered Yes to question #2, indicate as follows: A. Previous Name: B. Date and location of change: _ C. Reason for change: 3. Present address: Street, P.O. Box City State Zip 4. Home Phone: Business: Other: 5. Age: Date of Birth: Social Security#: 6. Weight: Height: Color Hair: Race: Sex: 7. Driver s License#: State: Expiration: 8. Are you currently: Married: Separated: Divorced: Single: 9. Full name of spouse Last First Middle 10. Name of person(s) to notify in the case of emergency: 1. Name Relationship Home Phone Work Phone 2. Name Relationship Home Phone Work Phone 11. List below any current or previous family member who was employed as a Fire Fighter:

8 A. Name Relationship Agency Home Phone Work Phone B. Name Relationship Agency Home Phone Work Phone CITIZENSHIP INFORMATION 1. Are you a citizen of the United States? Yes No 2. Naturalization: Date: Location: Number: CERTIFICATION REFERENCE INFORMATION 1. Are you presently certified or have you ever been certified as a Fire Fighter? Yes No If yes, date certified: State: 2. If not presently working as a fire fighter, date last worked as such: Date: Agency Name: 3. Number of years and months experience as a fire fighter: Years: Months: EDUCATION 1. Do you have a college or university degree? Yes No 2. Please circle degree: AA/AS BA/BS MA PhD 3. Number of semester hours: Quarter hours: 4. Major: Minor: FIRE FIGHTER EXPERIENCE Agency Phone Number Rank Date Employed Supervisor

9 EMPLOYMENT REFERENCES OTHER THAN FIRE FIGHTER EXPERIENCE List chronologically the last two employers, including part-time: 1. Name of Employer Dates Employed (From/To) Position Held Address City State Zip Name of Supervisor Telephone Number Reason for Leaving 2. Name of Employer Dates Employed (From/To) Position Held Address City State Zip Name of Supervisor Telephone Number Reason for Leaving Have you ever applied for a position with or been sponsored into basic training by any fire service agency? If yes, please list below: Agency Date Agency Date COURT RECORD 1. Have you been given a traffic ticket within the past five- (5) years? Any civil infractions? Yes No if yes, please list: Date Place Charge

10 COURT RECORD CONTINUED 2. Have you ever been arrested in any state for any criminal violation (felony or misdemeanor or contempt of court order)? Yes No if yes, please list below: Date Place Charge SPECIAL NOTE: Criminal records sealed under Florida Statutes, as most states, may be available for inspection by a public service agency for the purpose of employment. If convicted, has your record been expunged? If yes, please list: Yes No Date: City: County: State: Please answer the following in your own handwriting. Why do you want to become a Fire Fighter? ESSAY PORTION

11 Use this page to list any additional information. COMMENTS FORM SPECIAL NOTE: This page should also be used to list any pre-existing injuries you may have that may be aggravated by physical exercise or activity. Pre-existing injuries of a serious nature (back injuries, recent surgery, joint injuries or disease, etc.) must be medically cleared prior to participating in any physical activity or training. Please list so that the instructors will be aware so that they can work with you.