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First Name

Middle Initial

Last Name

Home Address

Email

Phone

Best Time to Call

Driver's License #

Driver's License State

Applying for:

Date Available to Begin Work

Will you relocate if the job requires it?

Yes

No

Are you lawfully authorized to work in the United States?

Yes

No

Employment History

Employer 1 (most recent)

Phone

Address

Starting Job Title

Ending Job Title

Immediate Supervisor Name & Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Employer 2

Phone

Address

Starting Job Title

Immediate Supervisor Name & Title

Ending Job Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Employer 3

Phone

Address

Starting Job Title

Immediate Supervisor Name & Title

Ending Job Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Please explain any gaps in employment

Have you ever been fired or asked to resign from a job?

Educational Background

School 1

# of Years Completed

Completed

School 2

# of Years Completed

Completed

# of Years Completed

Completed

School 3

Please select all current certifications/licensures from below

KY 300 Hour

KY EMT

KY Paramedic

NREMT

Out of State EMT/Paramedic

Please select all current certifications/licensures from below

IFSAC/ProBoard FF I

IFSAC/ProBoard FF II

IFSAC/ProBoard HazMat Awareness

IFSAC/ProBoard HazMat Operations

Please select all current certifications/licensures from below

KY Fire Inspector

KY Fire Instructor I

KY Fire Instructor II

KY EMS Instructor

References

Name

Phone

Title

Relationship to You

Email

# of Years Known

Name

Phone

Title

Relationship to You

Email

# of Years Known

Name

Phone

Title

Relationship to You

Email

# of Years Known

Background Check Documents

The completion & upload of these documents is required as part of the application process.

Background Check Documents

Upload File

.pdf or .doc file types only

Download Documents

Your Signature

Thank you for submitting your application! We will be in touch soon!

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