notice to applicant - lagrange...·the city of lagrange is an equal opportunity employer and...

CITY OF LAGRANGE • 200 RIDLEY AVENUE • LAGRANGE, GEORGIA 30240

EMPLOYMENT APPLICATION* Active for 30 days unless otherwise notified Date Applied _

NOTE: All fields must be answered fully in order to be considered for employment. Please ask for assistance if any portion of

application is unclear. All candidates will be required to pass a pre-employment drug test.

LAST NAME FIRST MIDDLE STREET ADDRESS CITY STATE ZIP

PHONE NUMBER SOCIAL SECURITY NO. YEARS AT ABOVE ADDRESS

MAJOR FIELDS OF EMPLOYMENT INTEREST AND POSITIONS DESIRED

AREYOU AVAILABLE TO WORK ANY TIME OFTHE DAY 0 YES 0 NO

ARE YOU AVAILABLE TO WORK ANY DAY OFTHE WEEK 0 YES 0 NO

RELATIVES WORKING FOR THE CITY OF LAGRANGE NAMES AND RELATIONSHIP (Past or Present)

ARE YOU A U.S. CITIZEN OR AN ALIEN AUTHORIZED TO BE EMPLOYED INTHE UNITED STATES? 0 YES 0 NO

IN CASE OF AN EMERGENCY NOTIFY ADDRESS PHONE (INCLUDE AREA CODE)

( )

HAVE YOU EVER BEEN CONVICTED FOR VIOLATING ANY LAW?

IF YES, PLEASE EXPLAIN.

0 YES 0 NO A YES WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT

MUST POSSESS A VALID DRIVER'S LICENSE. PLEASE COMPLETE THE FOLLOWING:

POSSESS A VALID DRIVER'S LICENSE GOOD DRIVING RECORD DRIVER'S LICENSE NO. DRIVER'S LICENSE CLASS/ENDORSEMENTS

YES NO YES NO

U.S.MILITARY HISTORY

BRANCH DATE ENTERED DATE DISCHARGED TYPE OF DISCHARGE HIGHEST RANK ATIAINED AND UNIT

INDICATE SPECIFIC SKILLS ACQUIRED IN THE U.S. ARMED FORCES

EDUCATI ONAL HISTORY

SCHOOL NAME AND LOCATION FROM TO LAST GRADE COMPLETED

DIPLOMA/DEGREE COURSE OF STUDY

HIGH SCHOOL

TRADE (OR APPRENTICE) SCHOOL

COLLEGE OR BUSINESS SCHOOL

OTHER

·The City of LaGrange is an equal opportunity employer and provides fair and equal employment opportunities to all applicants for employment and employees

without regard to race, color, religion, national origin, citizenship status, age, sex, disability, veteran's status, or political affiliation.

PLEASE COMPLETE BOTH SIDES AND ANSWER ALL QUESTIONS. ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED.

FORMER CITY EMPLOYEE

YES 0 NO 0

DEPARTMENT/DIVISION JOB TITLE & DUTIES FROM TO

USE THIS SPACE FOR COMMENTS ABOUT YOUR SPECIAL ABILITIES I.E. APPRENTICESHIPS, TOOLS, CERTIFICATIONS, EXPERIENCE, ETC.

NOTE: The City of LaGrange will conduct an extensive background check including contacting past employers, schools attended, and possibly a credit history. Please note

any employers you do not want contacted.

EMPLOYMENT HISTORY (PLEASE COVER EMPLOYMENT HISTORY FOR PAST TEN YEARS, INCLUDING MILITARY IF APPLICABLE) . USE ATTACHMENT IF NECESSARY.

(1) NAME OF EMPLOYER

(2) ADDRESS OF EMPLOYER,(3) PHONE NUMBER

FROM

MO./YR.

TO

MO./YR.

WAGE RATE

START/FINISH

JOB TITLE

AND DUTIES REASON FOR LEAVING

SUPERVISOR'S NAME

name

1address

phone (

name

2 address

phone

name

3 address

phone

name

4 address

phone (

PLEASE COMPLETE ALL AREAS ABOVE, WHETHER OR NOT A RESUME IS ATTACHED.

WORK REFERENCES WE MAY CONTACT (INCLUDE AT LEAST TWO MOST RECENT OR CURRENT SUPERVISORS)

Please read this important information below. Ask for clarification if needed.

The undersigned has applied for employment with the City of LaGrange and hereby authorizes the City of LaGrange to contact my current and former

employers and references for the purpose of acquiring information regarding me; I hereby authorize such employers and references to supply such informa tion verbally or in writing to the City of LaGrange. In consideration for their furnishing such information, I hereby waive any and all claims against such

former employers and references which may arise from their furnishing such information.

I understand the City of LaGrange has a Substance Abuse Prevention Program which includes drug testing. I agree to comply with applicable City policy. I understand that once offered a position I will be required to take a medical examination and drug screening.

I understand that once offered a position I may be required to pass a physical examination as a condition of continued employment.

I certify that the answers given by me to all of the questions on this application are to the best of my knowledge and belief, true and correct. I further

affirm that I have not knowingly withheld any facts or circumstances that would detrimentally affect my application for employment, and I understand

that any misleading or incorrect statement may render this application void and would be cause for dismissal, if employed.

Date Available for Work _ Applicant's Signature ------------------------

ADDRESS

OCCUPATION

ADDRESS

OCCUPATION

3

The following minimum guidelines are not all-inclusive, but are among the principal factors

considered in evaluating an applicant’s candidacy for employment. Any questions should be

directed to the LaGrange Fire Department, telephone 706-883-2650.

1. Not have been convicted of a felony in any jurisdiction within ten years prior to

employment/appointment (except as provided by OCGA 25-4-8). Applicants who have

by self-admission, committed crimes that were never detected shall be presumed to

have committed the crime or act. Pleas of Nolo Contendere are considered a

conviction.

2. No more than 1 DUI conviction or any DUI conviction in the past 5 years.

3. Must show a stable employment history.

4. Must have a credit history that reflects a pattern of credit stability. Must not have a

bankruptcy in progress nor any pending garnishment or civil judgment, which may

cause undue hardship while employed.

5. Must not have a history of illegal drug use. Shall not have used marijuana within

24-month period prior to date of application. Experimental usage of marijuana,

prior to the age of 21 will not be sole reason for disqualifying a candidate.

6. Must successfully complete a polygraph examination.

7. Must not have had license suspended or revoked for reasons other than nonpayment of

insurance premiums, in the last five years.

4

CITY OF LAGRANGE

FIRE DEPARTMENT

Employment Application

CONFIDENTIAL

QUESTIONNAIRE

APPLICANT’S NAME: _______________________________________________

Address:

Home Phone Number: Cell Number:

Email Address:

APPLICANT FOR:

The City of LaGrange is an equal opportunity employer and provides fair and equal employment opportunities to all applicants for employment without regard to race, color, religion, national origin, citizenship status, age, sex, disability, veteran's status, or political affiliation.

Packet Revised 11//29/2018

5

Firefighter

Job Description

A person in this position is highly skilled and extensively trained in the duties of life-saving and protecting

property from fire and other emergency situations. Work contains a substantial element of risk and employee

must be able to exercise good judgment independently in emergency situations. Employee is required to learn

and participate in operation of all firefighting equipment and acquire knowledge, skills and abilities in a variety

of related subjects. Other duties include maintenance of department equipment, apparatus and quarters for a 24-

hours period.

This employee is required to perform hazardous tasks under extreme emergency and highly stressful conditions

which require extended physical and mental exertion. This can include prolonged strenuous exertion, mental

and physical, under such handicaps and adverse conditions as smoke, fire, heat, bad weather, heights, cramped

surroundings, hazardous materials, unpredictable changing situations, and to do so in a safe and efficient

manner. The protection of lives, exposures and personal property constitutes the primary, most difficult and

most responsible areas of work. This individual is also required to gain knowledge in life saving techniques,

such as first aid, CPR and first responder training. Other important aspects of this job include rescue, vehicle

extrication, public education and fire prevention. This individual spends a major portion of time attending

training classes and drilling to learn and review methods, techniques, policies and procedures. Performs

scheduled duties in care and maintenance of department facilities, apparatus and equipment. Work is usually

performed in accordance with supervision and defined procedures, but performance of work does require

initiative and a thorough understanding of firefighting and fire prevention techniques and methods. No

supervision of others is exercised. Work is reviewed by the Lieutenant.

EXAMPLES OF WORK

The following examples of work and associated tasks are typically performed by a person in this position. No

attempt is made to be exhaustive in this listing.

Responds to fire alarm as part of a team

Performs fire ground operations such as forcible entry, ventilation, salvage, overhaul, ladder buildings, and

firefighting using acceptable methods and techniques as directed by the officer in command

Performs search and rescue to remove persons from danger and administers first aid/CPR

Operates equipment such as saws, generator, foam applicator, miscellaneous hand tools and connects hose

lays

Participates in clean-up and reloading of trucks and equipment, such as hose, breathing apparatus, nozzles

and hand tools used during an emergency

Responds to any and all emergency calls, such as vehicle accident, natural disasters, hazardous materials

spills and rope rescue calls

Operates Amkus tool to extricate victims

Performs first aid/CPR

Assists other city agencies as needed

Assists with evacuation of buildings or areas

Rig ropes, pulleys and related gear for rescue lines, safety lines, equipment lines and barricade lines

Assist other jurisdictions with rescue, fire suppression, investigation, hydrant maintenance and other related

operations

6

Attend and participate in training programs

Maintains firefighter certification

Completes basic inspection training

Completes first responder training (EMS)

Completes rookie firefighter training

Completes first aid/CPR training

Participates in daily classes in firefighting methods, techniques and tactics (240 hours per year)

Performs simulated fire ground tasks during standard operating procedures drills

Participate in live fire training such as house burns, flammable liquids and flammable gases

Participates in classes in streets, territories and landmark buildings

Participates in pre-fire planning classes of target areas

Attends out-of-town schools

Attends classes on home fire safety, public relations and fire ground safety

Participates in fire critiques

Participates in departmental planning sessions such as budget, specification writing, and special projects

Participates in departmental policy and procedure review sessions

Participates in driver training

Participates in annual service tests of all equipment

Participates in extracurricular education

Successfully complete requirements of NFPA 1001 (Firefighter Professional Qualifications)

Participates in community service activities

Demonstrates firefighting gear and equipment to schools, civic groups, club, etc.

Conducts fire station tours of various groups

Participates in community fund raising projects

Provides street and building location directions to the public

Gives home fire safety information to the public

Represents the fire department at civic functions

Participates in maintenance and cleaning of equipment, station and grounds

Clean trucks, tools and equipment, station and grounds

Checks equipment daily

Participates in maintenance duties of building and grounds as scheduled

Performs maintenance duties such as painting, minor repairs and grass cutting as assigned

Performs or participates in other related duties as required

Assists in first responder stabilization of injured civilians at vehicle accidents and other emergency

situations

Stand-by for controlled burn-offs, power lines down and helicopter landings

Assists training new firefighters

Writes statements and testifies in court

Fill in as relief Driver/Engineer (once certified relief driver)

Assist in recovery of drowning victims

Inspect buildings for compliance with fire prevention ordinances

Write fire inspection reports

Write basic incident reports

Subject to call-in 24 hours a day

7

KNOWLEDGE, SKILLS AND ABILITIES

Knowledge, or ability to acquire knowledge, of fire department organization, radio communications

procedures and fire behavior, including stages of a fire, heat sources, heat transfer and flashpoint

Knowledge of, and skill in use of, fire hose, nozzles and appliances, including their proper use, proper

advancement techniques, cleaning, proper connection procedures, hose rolls, hose carries, hose loads and

proper cleaning procedures, ladders, ladder techniques and safeguards

Knowledge of fire streams, water hammer, sprinkler systems and connections, standpipe systems, and

hydrant connections

Knowledge of building construction, basic physics, basic chemistry, math and electricity

Knowledge of fire extinguishers, home smoke detectors, policies, procedures, preventative maintenance,

flammable liquids and gases and extinguishment methods

Knowledge of City policy, departmental rule and regulations, standard operating procedures, departmental

scope of operation and size

Knowledge in fire prevention codes and standards, fire protection systems, city codes, environmental codes,

OSHA standards and NFPA standards

Skill in proper salvage techniques, folds and rolls of salvage covers, and purpose of salvage

Skill in overhaul techniques, including opening ceilings, walls and floors using the proper tools and

equipment for ventilation

Skill in the proper use of SCBAs, including cleaning and sanitizing, donning, and safety features

Skill in the use of, and knowledge concerning, forcible entry, safety in fire/emergency situations, and proper

safety use of ladders

Skill in search and rescue techniques, including rope rescue, trench rescue, extrication, Amkus tool

operation and providing emergency medical care

Ability to adapt to changing conditions and cope with stressful, life threatening conditions

Ability to communicate well, both orally and in writing

Ability to present a good public image

Ability to use good judgment in recognizing danger and safety to self and others

Ability to use common sense and make correct decisions in the absence of a supervisor

Ability to establish and maintain an effective working relationship with department employees, other City

employees, and the general public

Ability to follow instructions or orders

Ability to conform to LFD dress code

Ability to perform the physical requirements of the job, including lifting more than 50 pounds

Ability to maintain a high level of efficiency without direct supervision

DESIRABLE TRAINING AND EXPERIENCE

Five years previous experience as Firefighter

Knowledge of LaGrange street and hydrant system

College or Trade School and/or courses in fire science including Georgia Fire Academy certification

EMT I/A/Paramedic certification

Possess a Class E or F State of Georgia driver's license

NECESSARY SPECIAL REQUIREMENTS

Be at least 18 years of age

Possess high school diploma or GED equivalent

Satisfactorily complete the required training and gain Georgia Firefighter Certification within one (1) year

Live within one (1) hour of LaGrange

8

Have and maintain a working telephone

Have a good previous work record

Complete LFD Rookie School

Must pass Firefighter Phases I, II, III

Must pass (70%) the Written Test (Human Relations, Reading, Mechanical, Math)

Must pass Physical Agility Test

Must pass Oral Interview Test (70%)

Background Check/Polygraph Test

GCIC Fingerprint Check

Physical Examination/Drug Test

Must possess EMT I or P (pass within 24 months of hire)

Must possess valid Georgia E/F Driver’s License

Must possess NIMS 100, 200, 700, 800 (pass by the completion of Rookie School)

9

NOTICE TO APPLICANT

Please compete this booklet in its entirety and return it to The City of LaGrange Human

Resources Department or the LaGrange Fire Department. Answer all questions thoroughly and

honestly. The sooner we receive your completed booklet, the sooner we can begin the processing

of your application.

I can not stress enough the importance of the accuracy of your answers. The information,

which you supply in this booklet, will be compared with information provided by others

throughout the application process. You will be asked to verify these answers at the polygraph

examination. Any discrepancy or omission may result in your removal from this application

process. You may not be especially proud of something you have done in the past but you must

write it down! Many candidates are removed from the process for this reason each year. The tragic

irony is that what they omitted or falsified may not have excluded them from consideration.

It is important that you understand that the process involved in the selection of firefighters is labor

intensive and will require 90 to 180 days, a process consisting of background investigation,

testing, and employment assessment.

If you have any questions about the application process or clarification about any of the

questions contained in this booklet, please call us at (706) 883-2037.

City of LaGrange

Human Resources Department

200 Ridley Avenue

LaGrange, Georgia 30240-2726

******************************************************************************

VISION REQUIREMENTS

In order to pass the physical examination, which will be required for employment, you must have

corrected vision of 20/40 Acuity (Snellen) with or without correction. You must also be able to

distinguish colors in traffic control devices (red, green and amber).

10

APPLICANT: READ THIS FIRST

No other document, which you will prepare during your application for Firefighter, will be as

important as the attached booklet. It is in your own best interest to follow instructions carefully.

There are many more applicants for employment than there are available positions. A properly

completed document enables us to better evaluate your application. We may be unable to

process an incomplete document, and this may nullify your employment application.

ENTRIES MUST BE TYPED OR HANDWRITTEN

BY THE APPLICANT IN BLACK INK.

Before completing this document, closely read the instructions, which are written throughout.

There are a number of copies of official documents you are required to obtain, and some of these

documents may be necessary to adequately complete this booklet.

When mentioning persons, be sure to fully identify the individual by his/her full correct

name. Further, give complete address to determine street numbers correct street spellings,

apartment numbers, telephone numbers and zip codes.

When completing the residence portion of this booklet, be sure that you provide every address

where you have lived for the past ten years. Begin, in order, from your present address. If

necessary, call the appropriate person to find out the exact address and time period when you

resided at that address.

When completing the employment portion of this booklet, be sure you provide each employer

from your current employment going back to when you completed high school. If there was a

period of unemployment, enter it in the booklet in the same sequence and manner as if this were

another employer by indicating "from" and "to" and printing "UNEMPLOYED" in the block

headed "Name of Employer." If you worked more than one job at one time, place the major first

job and enter the part-time or secondary job in the block immediately after the primary position.

Finally, if you were ever involuntarily separated from a job [i.e. last month or twenty years ago],

include this in your employment record. If additional space is needed for any item, the

answer may be continued on a separate sheet of paper and attached.

11

►►NOTICE TO FIRE DEPARTMENT APPLICANTS◄◄

Applicants must submit and successfully complete the following:

1. An application package that will be reviewed for

thoroughness and accuracy as part of the hiring process.

2. A physical agility test.

3. An interview with members of LaGrange Fire Department and a written essay.

4. A written test.

5. Pass a thorough examination. Areas of questions consist of Work History, Driving

History, Criminal Violations, Use of Illegal Drugs, and Employment.

6. Pass a thorough investigation to include character, experience, background and physical

fitness.

7. An investigation of all police records, all previous employment, past places of

residence, personal habits including criminal conduct, military records, credit

history, educational background and other areas deemed pertinent.

8. A polygraph examination at City expense. Areas of questions consist of Work History,

Driving History, Criminal Violations, Use of Illegal Drugs, and Employment.

9. A drug screen.**

10. Upon an offer of employment, pass a physical examination.**

**These examinations are conducted after a conditional offer of employment has

been made.

12

MINIMUM REQUIREMENT FOR

FIREFIGHTER APPLICANTS

1. A high school education or its equivalent as recognized by the Georgia

Department of Education. (Minimum GED score of 45 per section-total 225.) 2. Certification as an EMT/I or EMT/P with the State of Georgia, within 2 years of

employment. 3. Pass the required background investigation, polygraph examination, and

physical examination. 4. Willing to work in harmony and on any shift or assignment. 5. Must be a U.S. Citizen or an Alien authorized to be employed in the United

States.

6. Must have a valid Georgia’s driver’s license or within the state you reside.

7. Certification of a State of Georgia Firefighter within 12 months of

employment.

8. Be in good physical condition as determined by a medical examination and

successfully pass the minimum physical agility requirements as established by

the GFSTC.

The City of LaGrange welcomes you as an applicant for a position with the

Fire/Rescue Department, but if you cannot meet or abide by the above stated

conditions and/or requirements, it is suggested that you not complete a formal

application as exceptions cannot be made. The City of LaGrange is an equal

employer.

13

PERSONAL INQUIRY WAIVER

AUTHORITY FOR RELEASE OF INFORMATION

TO WHOM IT MAY CONCERN:

I respectfully request and authorize you to furnish the LaGrange Police Department any and all

information, including that of a confidential or privileged nature, you may have concerning me.

This includes police records, court records, work records, school records, military records, credit

and financial records, internet activity, medical and mental records. This information will be

used to assist in determining my qualifications and fitness for employment with the LaGrange

Fire Department.

Intending to be legally bound hereby, I release you, your organization, and others contacted from

any liability or damage which may result from furnishing the information requested: Photostat

copies of this authorization carry the same authority as the original.

I also authorize the City of LaGrange c/o the LaGrange Police Department to receive any

criminal and/or driver history record information pertaining to me, which may be in the files of

any State or Local criminal justice agency in Georgia.

Full Printed Name Address

Sex Race Date of Birth Social Security Number

Signature of Applicant

Before me personally appeared who stated this document

and its intent was explained to he/she has full knowledge of its purpose and that he/she executed this instrument of

his/her own free will and accord.

Subscribed and sworn to me in my presence this day of , .

NOTARY SEAL

NOTARY PUBLIC

NOTE: YOUR APPLICATION WILL NOT BE PROCESSED IF THIS FORM IS NOT

PROPERLY COMPLETED.

14

Again, answer each question completely and honestly. Add extra sheets if you need more

space than provided. Many people are not accepted because of omissions and concealment

rather than because of previous behavior. While indiscretion or other situations in your

life history may or may not be condoned, deception will absolutely not be tolerated.

Finally, when you have fully completed this booklet return it to:

Human Resources Dept.

City of LaGrange

200 Ridley Ave

LaGrange, GA 30240-2726

You must furnish our department with one (1) copy each of the following documents:

1) Your Birth Certificate

2) Your High School Diploma/GED

3) Your college Transcripts

4) Your DD-214 (if applicable)

5) Your Naturalization Certificate (if applicable)

6) Your Driver’s License

7) Your Social Security Card

8) A copy of your Firefighter Certification or NPQ Equivalency.

9) A copy of your EMT/I/A or EMT/P certification

10) Photo Identification

IN ADDITION TO THE ABOVE:

11) RETURN THE ENCLOSED PERSONAL INQUIRY WAIVER COMPLETED

AND NOTARIZED. RETURN THE ORIGINAL ONLY; NO ADDITIONAL

COPIES ARE REQUIRED.

15

FAMILY BACKGROUND OF APPLICANT

Provide complete address, zip codes, and phone numbers.

Father: Last First Middle DOB

Address: Street Address City State Zip Code

Home Phone: Work Phone:

Mother: Last First Middle DOB



NOTE: If you were reared by anyone other than your parents, give the following information

concerning those who raised you below:

Name of Person: Last First Middle DOB



Spouse: Last First Middle DOB



Ex-Spouse: Last First Middle Date of Divorce



Ex-Spouse: Last First Middle Date of Divorce



16

List home addresses for the past ten years. (Work backwards, list current address first.) Attach

additional sheet if needed.

1. From: To:

2. From: To:

3. From: To:

4. From: To:

5. From: To:

6. From: To:

7. From: To:

17

EDUCATION / TRAINING / SKILLS

HIGH SCHOOL/VOCATIONAL SCHOOL GRADUATED FROM:

SCHOOL ADDRESS CITY/STATE/ZIP DATE

Graduated High School/GED awarded:

Highest Grade Completed:

COLLEGE/UNIVERSITIES

What colleges or universities have you attended? (List most recent first and work backwards.)

COLLEGE/UNIVERSITY LOCATION GRADUATED MAJOR

Yes No

Yes No

Yes No

Have you ever been suspended or expelled for academic probation from any school? Yes

No If yes, explain.

FOREIGN LANGUAGE SKILLS

Are you able to communicate in any language other than English (including sign language)? Yes

No If yes, specify and state fluency and reading levels:

18

MILITARY STATUS OF APPLICANT

Have you served in the armed forces of the U.S.? Yes No

If yes, branch of service:

Date of Service From: To:

Type of Discharge: (Exclude Medical Reasons)

Any reserve obligation: Yes___No

If yes, supply reserve organization name and address below:

Organization:

Address:

Supervisor: Business Phone:

Were you ever subject to any type of disciplinary action while serving in the Armed Forces? Yes

No If yes describe in detail.

Have you ever been denied entrance to any of the Armed Forces? Yes No If yes, explain

the basis for your denial (except for Medical Reasons).

19

OTHER FIRE DEPARTMENT APPLICATIONS

List all other fire departments with which you have applied for employment.

Department Dates Status

20

APPLICANT'S EMPLOYMENT BACKGROUND

List all employment including part-time, beginning with current employer first, and work

backwards FOR A PERIOD OF TEN (10) YEARS. You must include any employment from

which you were terminated, regardless of when it occurred in your work history.

Current Employer: Organization:

Address: Phone:

Applicant's Supervisor:

Applicant's Position:

Dates of Employment: From: To: Reason for leaving:

(Exclude Medical Reasons)

We will contact your current employer in the course of our background investigation.

Supervisor’s Name:________________________ Telephone:

******************************************************************************

Organization :

Address: Phone:



Dates of Employment: From: To: Reason for Leaving:


******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





21

******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





******************************************************************************

Organization :

Address: Phone:





22

If you answer "yes" to any of the questions below, give full details including the name and

address of each employer, approximate dates, and the circumstances in each case.

Have you ever been discharged or disciplined at any employment?

Yes No If yes, explain.

Have you resigned (quit) while anticipating that your employer intended to discharge (fire) you

for any reason?


Have you ever resigned (quit) while anticipating that your employer intended to take any form of

disciplinary action against you?


Have you ever had any extended work absences for reasons other than medical or earned

vacations?


_

23

MISCELLANEOUS

SPECIAL SKILLS / TRAINING

DO YOU HAVE SKILLS OR TRAINING IN THE FOLLOWING AREA?

SKILL/TRAINING NO YES SPECIFY

COURSE/CERTIFICATION

EMT/Paramedic

Emergency Driving

Firefighting

Hazardous Materials

Leadership

Aircraft Rescue

MIS/Computers

Other (Specify)

Is there anything else in your background that you feel we should be aware of as we consider

your employment application? Yes No (if yes, explain)

FIREFIGHTER EXPERIENCE

Do you have experience as a certified firefighter? Yes No if yes, explain:

Do you have experience as a volunteer firefighter (non-certified)? Yes No If yes, explain

Do you have experience as a volunteer, cadet, explorer with this or any other agency?

Yes___No___If yes, explain: _________________________________________

24

PERSONAL REFERENCES

List ten (10) personal references that may be contacted between 8 A.M. and 5 P.M.

Monday thru Friday. References should be individuals who are not related to you

and who have known you for at least 5 years.

PLEASE PRINT

NAME:

STREET ADDRESS:

CITY & STATE:

OCCUPATION: CELL PHONE:

HOME PHONE: WORKPHONE:

EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

25

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

NAME:

STREET ADDRESS:

CITY & STATE:



EMAIL ADDRESS:

26

APPLICANT'S MOTOR VEHICLE/LICENSE INFORMATION

1. List all motor vehicles currently owned or operated by applicant.

Make: ___________ Model:____________ Tag Number: _______________



2. Motor vehicle insurance company (s):

Address:

Agent: Phone No:

3. Has your automobile insurance ever been cancelled for any non-medical reason?

Yes No If yes, explain:

4. List all current and past driver's licenses issued to applicant:

Number: State: Type:

Valid? Yes No Expiration: Restrictions:


Valid? Yes No


Valid? Yes No

5. Has your license or privileges to operate a motor vehicle ever been revoked, refused,

suspended, or canceled? Yes No (If yes, explain in detail supplying reason, dates,

location, etc).

6. Has your vehicle registration ever been canceled, refused, revoked or suspended for any

reason? Yes No (If yes, explain):

7. Have you ever been arrested or charged with DRIVING WHILE INTOXICATED or

DRIVING UNDER THE INFLUENCE? Yes No (If yes, explain):

27

8. To the best of your knowledge, how many points are currently on your driver's license?

points.

9. How many years have you been driving?

10. What type of equipment have you been driving?

11. Have you received any safe driver awards?

award or certificate?

If yes, can you furnish a copy of the

12. Have you received driver's education? If yes, furnish a copy of the certificate?

28

TRAFFIC RECORD

List all traffic violations (excluding parking tickets) you have received.

******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

Violation: Date:

Disposition:

Agency location: ******************************************************************************

29

TRAFFIC ACCIDENTS

List all traffic accidents in which you were as the driver of the vehicle.

******************************************************************************

Date: City: State:

Was citation issued? Yes No If yes, what violation:

Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

Date: City: State:


Disposition:

******************************************************************************

30

CRIMINAL HISTORY

Have you ever committed or participated in any of the following crimes

(whether you were caught or not)?

CRIME YES NO CRIME YES NO

Vandalism

Telephone

Child Abuse or Molestation

Computer Related Crimes

Hunting/Fishing Law

Violations

Impersonating a Police

Officer

Trespassing

Assault

Arson

Weapons Violation

Theft or Unauthorized Use of

a Motor Vehicle

Aided or Abetted in the

Commission of a Crime

False Alarms

Fraud (Bad Checks)

Embezzlement

Sexual Assault

Extortion

Public Intoxication

Prostitution

Disorderly Conduct

Thefts

Wiretapping

Perjury

Burglary

Bigamy

Robbery

Giving False Information

Other

Any Drug Related Crime

Any Gang Crime

IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN IN DETAIL.

PROVIDE ADDITIONAL SHEET IF NECESSARY. INCLUDE DATES AND

DISPOSITION.

31

CRIMINAL HISTORY

Have you ever been arrested, interviewed, interrogated, or detained by any law enforcement

agency? Yes No (If yes, explain in detail below giving date, reason, agency and

disposition.)

Have you ever been placed on probation or parole? Yes

below giving date, reason, authority and disposition.)

No (If yes, explain in detail

Have you ever been convicted of a criminal offense? (Exclude traffic related offenses). Yes

No (If yes, provide all details).

Are you friends with anyone whom you suspect of being a seller of illegal drugs?

Yes No (If yes, explain in detail)

32

HAVE YOU EVER:

1. Been present at, witness to, or involved in any way

in any kind of murder, killing, manslaughter, or other

unnatural death of a human being? Yes

No

2. Has your car been used in the commission of a crime? Yes No

3. Have you been named in any manner, in a civil law suit? Yes

No

4. Have you used any illegal drug in the past five (5) years? Yes No

5. Have you ever been a member of a gang Yes No

If you answered yes to any of the above questions, explain fully.

Is there anything in your past, which if revealed at a later date, may prove to be embarrassing to

you or to the Fire Department, if employed? Yes No (If yes, explain in detail.)

33

I CERTIFY THAT ALL ENTRIES MADE BY ME IN

THIS BOOKLET ARE TRUE, COMPLETE AND

CORRECT TO THE BEST OF MY KNOWLEDGE. I

FURTHER UNDERSTAND THAT IF AT ANY TIME

DURING THE COURSE OF THE BACKGROUND

INVESTIGATION OR DURING MY

EMPLOYMENT WITH THE LAGRANGE FIRE

DEPARTMENT, IT IS DISCOVERED THAT I

HAVE MADE ANY UNTRUTHFUL STATEMENT,

FALSIFIED MY APPLICATION OR GIVEN ANY

MISLEADING STATEMENTS, IT SHALL BE

SUFFICIENT CAUSE FOR MY IMMEDIATE

TERMINATION.

I FURTHER UNDERSTAND THAT IF I AM NOT

HIRED, I CAN REAPPLY

AFTER ONE YEAR IF THIS IS THE FIRST

ATTEMPT.

AFTER THREE YEARS FOLLOWING THE

SECOND ATTEMPT AND EACH ATTEMPT

THEREAFTER.

Signature of Applicant

Print Name

Date

34

Physical Agility Test

PERSONAL INJURY WAIVER

Applicant's Name:

Date of Birth:

Social Security Number:

WAIVER

I, the above named applicant, hereby release the City of LaGrange or any of its officials or

authorized representatives from any liability or damage for any physical injury which may result

from performing the physical agility test as part of the testing for the position of Firefighter.

Applicant's Signature Date

Applicant's Complete Address

AFFIDAVIT

State of

County of

Before me personally appeared the said who says that he

executed the above instrument of his own free will and accord, with full knowledge of the

purpose thereof.

Sworn to and subscribed in my presence this day of , .

Notary Public

SEAL My commission expires

35

How did you hear about our department?

Internet

Social Media, if so which site_________________________________

Newspaper, if so which one?

Job Fair, if so on what date?

Person, if so, whom?

LGTV Other

36

CITY OF LAGRANGE SUPPLEMENTAL APPLICATION

FIRE/RESCUE DEPARTMENT

NAME: DATE: _

The information supplied on the supplemental form will become a permanent part of the

employment application.

Please answer the following question in the space provided below.

Why do you want to become a Firefighter and what do you feel is the scope of

job responsibility of a Firefighter?

Please utilize the full page in answering and elaborate on your statements. Date Signature (In Full)

37

PHYSICAL AGILITY TEST

LAGRANGE FIRE/RESCUE DEPARTMENT

Descriptions of Task:

The physical agility course shall be performed while wearing full protective clothing and

SCBA. The SCBA has an approximate weight of 25 Lbs. The candidate SHALL NOT wear

a SCBA face piece, nor breathe air from the SCBA.

1. TASK I - HOSE CARRY Task Description

The candidate shall place on his/her shoulder and/or carry two (2) 50 ft sections of 1

3/4” hose weighing approximately 20 lbs up the exterior flight of stairs, to the

Second floor, then down the interior flight of stairs. The candidate must use each

step while climbing or descending the stairway. This exercise simulates moving

hose up and down stairs as found in high rise fire situations. After completion,

proceed to station 2.

a. Physical Abilities Measured

Leg strength and endurance; cardiovascular endurance.

b. Physical Abilities Required

Leg, arm, back strength; cardiovascular endurance.

2. TASK II - PIKE POLE PULL Task Description

The candidate shall grasp the pike pole with both hands and pull the handle

downward until the butt touches the floor, then return it to its original position.

Repeat twenty-five (25) times. The pike pole in this exercise will be a 7ft pike pole

connected to a rope that is attached to two 50’sections of 1 3/4” hose weighing

approximately 40lbs. NOTE: When performing this exercise the candidate shall

stand upright, flat footed and reach up to grasp the pike pole. At no time shall the

candidate grasp the pike pole higher than the point at which he/she can grasped the

pole while standing flat footed. This exercise simulates using manual hand tools

(pike pole) to pull ceiling material down. After completion, proceed to station 3.


Arm, grip, back strength..


Leg, arm, grip, back strength.

38

3. TASK III – LADDER REMOVAL AND REPLACEMENT Task

The candidate, given a 14-foot roof ladder placed in a horizontal position, at a

height of five (5) feet, and with the ladder rungs in a vertical position, shall lift the

ladder from its supports and place the ladder on the ground, removing hands, then

picking the ladder back up and returning it to its original position. This exercise

simulates removing a ladder from the side of an engine company, and moving it on

a fire scene. After completion, proceed to station 4.


Back, arm, leg, grip strength.



4. TASK IV – RESCUE DRAG Task Description

The candidate, given a 165 Lb (pound) dummy, on a level surface, shall drag the

dummy a distance of fifty (50) feet. After completion, proceed to station 5.


Leg, arm, grip, chest, strength, and endurance.


Leg, arm, grip, chest, strength and endurance; cardiovascular

endurance.

5. TASK V – EQUIPEMENT CARRY Task Description

The candidate shall pick up two (2) 20 Lb. (Pound) fire extinguishers and carry a

distance of 50 Ft., then sit the fire extinguishers on the ground. After Completion,



Leg, arm, grip, back strength, cardiovascular condition.



6. TASK VI – HOSE ADVANCEMENT Task Description

The candidate, given a 1 ¾” charged fire hose, 150 ft. in length, shall pick up the

nozzle and advance the charged hose line for a distance of 50 ft. After reaching the

destination, the candidate shall lay the hose on the ground. After completion,



Leg, arm strength, balance.

39



7. TASK VII- LADDER EXTENSION Task Description

The candidate, given a 24-foot aluminum extension ladder in a securely supported

vertical position, must completely extend the fly section (top section) of the ladder,

making sure the ladder locks in place. The candidate must then lower the fly section

in a controlled fashion to the starting position. After completion, proceed to station

8.


Arm, grip, back strength.



8. TASK VIII – FORCIBLE ENTRY/VENTILATION SIMULATION

(Keiser Sled)

Candidate straddles a 165 lb beam while standing on two 10” wide and 8’ long

runners placed about 15 in apart. Using an 8-lb dead blow hammer, the candidate

strikes the end of the beam repetitively, driving it a distance of 5 ft. After

completion, the test is complete.




Leg, arm strength, balance

notice to applicant - lagrange...·the city of lagrange is an equal opportunity employer and...

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