----------------

wwwCltyofKokomoorg 765-456-7470

APPLICATION FOR EMPLOYMENT The City of Kokomo (City) is an equal opportunity employer Applicants are considered for employment wHhout regard to race color religion sex age disability national origin or any other legally-protected status unless such status constitutes a bona fide occupational qualification The City will comply with its legal obligation to provide reasonable accommodation to qualified individuals with disabilities and for relialous beliefs

PLEASE PRINT

Date of Application _______________ Positlon(s) Desired ___________________

PERSONAL INFORMATION

Name ______~=-------------~~~--------------~~~---------------------LAST FIRST MIDDLE

Address __~~~-~~~----------------~~--------~~~--------------~~= NUM8ER STREET CITY STATE ZIP CODE

Telephone No (1) ( (2) (

If you have resided at your present address fewer than three years list your prior address

Addm~ __~~=_~~~--------------------~~--------~~=_------------------~~~NUMBER STREET CITY STATE ZIP CODe

Are you available to work 0 Full Time o Part-Time o Temporary o Other Explain ________________DOn-Cali o Overtime o Any Shift

What date will you be available for work __________ Expected Rate of Pay __________________

Are you on a layoff and subject to recall at another employer DYes 0 No

Have you filed an application with the City before 0 Yes 0 No If yes give date(s) _______________

Have you ever been employed with the City before 0 Yes 0 No If yes give date(s) department(s) and supervisor(s)

Do you have any mlatlves or friends employed here 0 Yes 0 No If yes please list by name and relationship

Why did you apply for a position with the City ___________________________________

Explain the reasons you would make a valuable employee of the City _____________________

Are you legally authorized to work in the United States 0 Yes o No

Will you now or In the future require sponsorship for employment visa status (eg bull Hmiddot1 B visa status) DYes 0 No

Are you 18 years or older 0 Yes o No Do you have a valid Indiana drivers license 0 Yes 0 No

Do you live within the city limits of the City of Kokomo o Yes o No

Have you been convicted of or pled guilty to a felony or misdemeanor other than a minor traffic-related infraction 0 Yes 0 No

If yes state the nature of the conviction or plea the date the court and the Jurisdiction and explain __________

Do you have any pending charges for a felony or misdemeanor other than a minor traffic-related Infraction 0 Yes 0 No

If yes state the nature of the pending charges the date the court and Jurisdiction In which they are pending and the cause number and explain _____________________________________

(A conviction plea or pendIng charges HI not necessarily disqualify you from consideration for employment The effeet of a comiletlon plea orpending charres will be assessed with raspect to time ciroumstances seriousness of the offense and job respon81b1litlfls and duties rPUC (allure tomiddotst II convlctlqn bouyer wHl diMluaify you (rom COQSideratton for emvmnf or Will mutt In leminatlol1ofemDloymeal lfwbSsecttluenty dlscqyerpd

For purposes of verifying past employment and schools attended please list any other names you have used

EDUCATION

Type of School

Name of School City and State

Number of Years

Completed

Graduate Course Pursued Degrees Gran~Yes No

High School

College or UniversIty

Business Trade or Technical School

Identify any special job-related skills and qualifications acquired from education employment volunteer work or military service

Identify specifiC skills related to technology communications customer service machines tools or other equipment that will be helpful in performing the responsibilities of the positlon(s) for which you are applying _______________

Identify the previous jobs you liked best and describe why _______________________

Iden~ify the previous J9bS you liked feast and describe why ________________________

How did you learn of this employment opportunity 0 Friend 0 Relative 0 Job Posting 0 Job Hotline 0 Job Fair o Website 0 Friend 0 Other ______

PERSONAL REFERENCES

List the name address and telephone number of three references who are not related to you and are not previous employers

1________________________________~____________~____~_________________________ Name Addre88 Telephone No

2__________________________________~--~~------~----~--------------------~----

Name Address Telephone No 3______________________ ~____~__~__~(____~)____________________~~_~~~__ Name Address Telephone No

EMPLOYMENT RECORD

Starting with your present or most recent job list ID your employment experience Including part-time or temporary employment Do not omit any experience You may Include job-related military service assignments and volunteer activities that reflect your qualifications for employment RESUMES MA Y BE SUBMITTED BUT WILL NOT BE ACCEPTED IN PLACE OF THE INFORMA TION REQUESTED BELOW

Employer Employmenl Dales Kind of Work Performed shyFrom

Acldrebullbull To

~phone ( ) SalaryHourly Rat

Job flUe Starting Reason for Leaving Immediate SupenillOr

I Final

o Discharged 0 Voluntary Resignation o Involuntary Resignation

Employer Employment Dat1 Kind of Work Performed From

Addre To

Telephone ( ) SalaryHourly Rate

JOb me Starting Reason for Leaving o Discharged 0 Voluntary Resignation Immediate SUpervisor Final o Involuntary Resignation

Employer Employment Date Kind 01 Work Performed From

Acldre To

Telephone ( ) SalaryHourly Rate

Job Till Slarting Reason for Leaving Immediate SUpervisor Final

n Discharged 0 Voluntary Resignation Dmiddot Involuntary Resignation

Employer Employment Dates Kind of Work Performed From

Address To

Telephone ( ) SalaryfHour1y Rat - shy

Reason for Leaving Job TlU Starting

Immediale Supenilsor Final o Discharged 0 Voluntary Resignation o Involuntary Resignation

Employer Employment Dates Kind of Work Performed f--- ---shy

Fiom

Addrell To

Talephone ( ) SalaryHourly Rate ---shyReason for Leaving Job Tide Starting

Immediate Supervisor Final o Discharged 0 Voluntary Resignation o Involuntary Resignation

If you need additional space please continue on a separate sheet of paper

May we contact the employers listed above 0 Yes 0 No If no indicate which one(s) you do NOT wish us to contact and provide the reason why you prefer that we do not contact the employer(s) _____________------_

Have you ever been discharged permitted to resign rather than be discharged or asked to resign from any position DYes 0 No If yes please state the employer and the reason for the discharge or resignatlon ___________

APPLICANTS STATEMENT (Please Indicate that you have read and understand each paragraph of the

Applicants Statement by elJtclng youe Initials beside tach Pfragraczb)

I completed this application and confirm all Information In It is TRUE and COMPLETE to the best of my knowledge I understand that false misleading or omitted information may result In the rejection of my application the revocation of an offer of employment or discharge

I authorize Investfgatlon of all statements in this application to arrive at an employment decisIon I understand that an investigation may be made and Information may be obtained through Interviews with personal references and past employsrs a credit check a criminal history check andor a drivers record check This Inquiry may Include Information as to among other things my charecter general reputation and personal characteristics as well as Information about my work performance and workplace conduct I consent to this Investigation and to the consideration of any statements of references former employers or others that are given in response to the Inquiry If the City decides to obtain a consumer credit report I understand that It will provide at my request the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of Information contained In suCh report

I release aU parties including but not limited to the City personal references and previous or current employers from liability for any Injury or damage that may result from their furnishing information concerning me or any action the City takes on the basis of such information

I understand that If I am offered a job as a condition of beginning my employment I may be required to undergo a physical examination and drug screen and I authorize any service provider or medical facility to furnish any medical Information with reference to me In conjunction with that examination and related considerations

____ I understand that all Individuals hired must produce certain documentation to verify their Identity and United States citizen status or If aliens their legai authorization to work In the United States I understand that an offer of employment Is contingent upon my producing the required documentation withlnthe legal time period

I understand that this application is not and is not intended to be a contract of employment and that any resulting employment is not for a fixed period of time and Is terminable at any time and for any reason by me or by the City I further understand that statements that may be contained In policies practices handbooks or other material do not create a guarantee of employmerit and that the City has the right to modify amend or terminate policies practices benefits plans or other programs within the limits and requirements Imposed by law runderstand that no the City representative other than an officer has the authority to enter into any agreement for any specific period of time or to make any different agreement and that such agreement mu~t be In writing and signed by both parties to be binding

I confirm that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that the City offered to me nor am I In possession of nor will I at any time reveal to the City under any circumstances anyproprfetary or confidential Information that is the subject of any contract non-dlsclosure agreement or prior work relationship

Date ______________________ Signature of Applicant

THIS APPLICAnON WILL liQI BE CONSIDERED ACTIVE AFTER 60 DAYS

CPAT

You are Required to have a current CPAT Card at the time of your

application CPAT is the required physical agility test

CPAT Testing is done by ESEC Emergency Services

For more information on CPAT Testing contact

ESEC Emergency Services

400 N High School Road

Indianapolis IN 46214

(317) 988-7703

May 4th 2013 with be ((Kokomo Day at ESEC however you may take

the CPAT Test at ESEC any day offered prior to May 24th 2013

Wayne Township Emergency Services Education Center - CPAT F AQ Page 1 of 1

Schools amp Programsbull ISIC Emergenc) Services Education Center phone 317 966 7703 Wayne TownshIP

ESEC EMERGENCY SERVICES EDUCATION CENTER

SerVI((S amp links

Home About Us Courses amp Training Services Offered Conference Center Rental

Facilities Contact Us Registration Photo Gallery Vincennes University Offerings

CPATmiddot Frequently Asked Questions What Is the renon for waiting 8 weeks after Orientation to test The 6 week waiting period is set by the International Association of Firefighters nil association feels the 6 week period bull suffiCient amount of time for anyone to prepare themselves property to pass the physical ability test

Can I waive the B week waiting periOd Yes This Is your choice However you will Ill giving UP all your Dractice sessions and must sign a waiver the day you take tile test

Can I practice after I have attended Orientation and before I test Yes you may practice on any of our scheduled OrientationTest dates at no charge Two (2) timed test dates will be made available between your Orientation and Test date Practice is held from 745 AM 6JO AM on all dates we are at the [PAT facility

Ciln I take the CPAT test the same day that I attend Orlentation7 We do not recommend this However if this is your choice you can do so by registering for your Orientation date and sending an email reQuestinq a test appOintment time to be set up directly after Orientation is completed You will receive a confirmation email

What happens if I fail the test You may re-test as many time as you would like The retest tost S $6000 You can register on-line by clOSing out of this wmdow and clicking on [PAT Re-test or Renew CPAT Card You will select the date you want to re-test then you will receve an email with the apPOintment time available for the date of your choice

How long does the CPAT card lut7 Expiration of CPAT cards are up to each Individual Fire Dept However most Departments accept the CPAl card for one year

How long doe the Orientation last You need to arrive on time Orientation does not last long at all You wiflilot be there longer than 1 hour

How should I dreSf for Orientation Dress casual you Will not be going through the events at Orientation unless you want to try it after you have completed Orientation

When Orientation and Telting I on the Ame day I dont have to go through Orientation a 2nd time do I When ~ou show up to the CPAT facility yOU will be aske~ Are you here for Orientation or for Testing The Orientation group will De sent one direction and the Test group will be sent another direction

How should I dress for the CPAT Tn You must wear long pants (Short pants are not allowed) You must wear closed toe shoes such as tennis shoes (No open toed shoes are allowed)

How long will I be there for the CPAT test and should I brin9 anythln9 with me You will be given an appOintment time to test Test aPPOintments are scheduled in two hour time Increments You shOuld not be there any longer than 2 hours 10 minutes and 20 seconds after your scheduled time Please dress comfortably for the test and bring your identification With you

ESEC accept Cash CheckS Visa ilnd MasterCard ESEC Refund Policy Note All cancellations must be in writing and emailed or mailed to ESE[ before refund will be Issued bull 100 Refund four (4) weeks prior to start date bull 50 Refund Between two (2) and four (4) weeks prior to start date bull No Refund After (2) weeks prior to start dete bull There will be a $10 charge 00 ali credit card refunds due to charges Incurred by ESEC

ESEC Emergencv Services S~Ialtt updted fo4rc~ 11 2013Phone 3119887703700 N High High School Rd DIego 11 Wts lt~i ~i~ ~~~l~Fa 3172487931

Indianapolis Indiana 46241 Qutstton5JCommentsl _FHltL=

httpwwwwaynek12inusleseccpat_ faqasp 31192013

EMPLOYMENT RECORD

Starting with your present or most recent job list ID your employment experience Including part-time or temporary employment Do not omit any experience You may Include job-related military service assignments and volunteer activities that reflect your qualifications for employment RESUMES MA Y BE SUBMITTED BUT WILL NOT BE ACCEPTED IN PLACE OF THE INFORMA TION REQUESTED BELOW

Employer Employmenl Dales Kind of Work Performed shyFrom

Acldrebullbull To

~phone ( ) SalaryHourly Rat

Job flUe Starting Reason for Leaving Immediate SupenillOr

I Final

o Discharged 0 Voluntary Resignation o Involuntary Resignation

Employer Employment Dat1 Kind of Work Performed From

Addre To

Telephone ( ) SalaryHourly Rate

JOb me Starting Reason for Leaving o Discharged 0 Voluntary Resignation Immediate SUpervisor Final o Involuntary Resignation

Employer Employment Date Kind 01 Work Performed From

Acldre To

Telephone ( ) SalaryHourly Rate

Job Till Slarting Reason for Leaving Immediate SUpervisor Final

n Discharged 0 Voluntary Resignation Dmiddot Involuntary Resignation

Employer Employment Dates Kind of Work Performed From

Address To

Telephone ( ) SalaryfHour1y Rat - shy

Reason for Leaving Job TlU Starting

Immediale Supenilsor Final o Discharged 0 Voluntary Resignation o Involuntary Resignation

Employer Employment Dates Kind of Work Performed f--- ---shy

Fiom

Addrell To

Talephone ( ) SalaryHourly Rate ---shyReason for Leaving Job Tide Starting

Immediate Supervisor Final o Discharged 0 Voluntary Resignation o Involuntary Resignation

If you need additional space please continue on a separate sheet of paper

May we contact the employers listed above 0 Yes 0 No If no indicate which one(s) you do NOT wish us to contact and provide the reason why you prefer that we do not contact the employer(s) _____________------_

Have you ever been discharged permitted to resign rather than be discharged or asked to resign from any position DYes 0 No If yes please state the employer and the reason for the discharge or resignatlon ___________

APPLICANTS STATEMENT (Please Indicate that you have read and understand each paragraph of the

Applicants Statement by elJtclng youe Initials beside tach Pfragraczb)

I completed this application and confirm all Information In It is TRUE and COMPLETE to the best of my knowledge I understand that false misleading or omitted information may result In the rejection of my application the revocation of an offer of employment or discharge

I authorize Investfgatlon of all statements in this application to arrive at an employment decisIon I understand that an investigation may be made and Information may be obtained through Interviews with personal references and past employsrs a credit check a criminal history check andor a drivers record check This Inquiry may Include Information as to among other things my charecter general reputation and personal characteristics as well as Information about my work performance and workplace conduct I consent to this Investigation and to the consideration of any statements of references former employers or others that are given in response to the Inquiry If the City decides to obtain a consumer credit report I understand that It will provide at my request the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of Information contained In suCh report

I release aU parties including but not limited to the City personal references and previous or current employers from liability for any Injury or damage that may result from their furnishing information concerning me or any action the City takes on the basis of such information

I understand that If I am offered a job as a condition of beginning my employment I may be required to undergo a physical examination and drug screen and I authorize any service provider or medical facility to furnish any medical Information with reference to me In conjunction with that examination and related considerations

____ I understand that all Individuals hired must produce certain documentation to verify their Identity and United States citizen status or If aliens their legai authorization to work In the United States I understand that an offer of employment Is contingent upon my producing the required documentation withlnthe legal time period

I understand that this application is not and is not intended to be a contract of employment and that any resulting employment is not for a fixed period of time and Is terminable at any time and for any reason by me or by the City I further understand that statements that may be contained In policies practices handbooks or other material do not create a guarantee of employmerit and that the City has the right to modify amend or terminate policies practices benefits plans or other programs within the limits and requirements Imposed by law runderstand that no the City representative other than an officer has the authority to enter into any agreement for any specific period of time or to make any different agreement and that such agreement mu~t be In writing and signed by both parties to be binding

I confirm that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that the City offered to me nor am I In possession of nor will I at any time reveal to the City under any circumstances anyproprfetary or confidential Information that is the subject of any contract non-dlsclosure agreement or prior work relationship

Date ______________________ Signature of Applicant

THIS APPLICAnON WILL liQI BE CONSIDERED ACTIVE AFTER 60 DAYS

CPAT

You are Required to have a current CPAT Card at the time of your

application CPAT is the required physical agility test

CPAT Testing is done by ESEC Emergency Services

For more information on CPAT Testing contact

ESEC Emergency Services

400 N High School Road

Indianapolis IN 46214

(317) 988-7703

May 4th 2013 with be ((Kokomo Day at ESEC however you may take

the CPAT Test at ESEC any day offered prior to May 24th 2013

Wayne Township Emergency Services Education Center - CPAT F AQ Page 1 of 1

Schools amp Programsbull ISIC Emergenc) Services Education Center phone 317 966 7703 Wayne TownshIP

ESEC EMERGENCY SERVICES EDUCATION CENTER

SerVI((S amp links

Home About Us Courses amp Training Services Offered Conference Center Rental

Facilities Contact Us Registration Photo Gallery Vincennes University Offerings

CPATmiddot Frequently Asked Questions What Is the renon for waiting 8 weeks after Orientation to test The 6 week waiting period is set by the International Association of Firefighters nil association feels the 6 week period bull suffiCient amount of time for anyone to prepare themselves property to pass the physical ability test

Can I waive the B week waiting periOd Yes This Is your choice However you will Ill giving UP all your Dractice sessions and must sign a waiver the day you take tile test

Can I practice after I have attended Orientation and before I test Yes you may practice on any of our scheduled OrientationTest dates at no charge Two (2) timed test dates will be made available between your Orientation and Test date Practice is held from 745 AM 6JO AM on all dates we are at the [PAT facility

Ciln I take the CPAT test the same day that I attend Orlentation7 We do not recommend this However if this is your choice you can do so by registering for your Orientation date and sending an email reQuestinq a test appOintment time to be set up directly after Orientation is completed You will receive a confirmation email

What happens if I fail the test You may re-test as many time as you would like The retest tost S $6000 You can register on-line by clOSing out of this wmdow and clicking on [PAT Re-test or Renew CPAT Card You will select the date you want to re-test then you will receve an email with the apPOintment time available for the date of your choice

How long does the CPAT card lut7 Expiration of CPAT cards are up to each Individual Fire Dept However most Departments accept the CPAl card for one year

How long doe the Orientation last You need to arrive on time Orientation does not last long at all You wiflilot be there longer than 1 hour

How should I dreSf for Orientation Dress casual you Will not be going through the events at Orientation unless you want to try it after you have completed Orientation

When Orientation and Telting I on the Ame day I dont have to go through Orientation a 2nd time do I When ~ou show up to the CPAT facility yOU will be aske~ Are you here for Orientation or for Testing The Orientation group will De sent one direction and the Test group will be sent another direction

How should I dress for the CPAT Tn You must wear long pants (Short pants are not allowed) You must wear closed toe shoes such as tennis shoes (No open toed shoes are allowed)

How long will I be there for the CPAT test and should I brin9 anythln9 with me You will be given an appOintment time to test Test aPPOintments are scheduled in two hour time Increments You shOuld not be there any longer than 2 hours 10 minutes and 20 seconds after your scheduled time Please dress comfortably for the test and bring your identification With you

ESEC accept Cash CheckS Visa ilnd MasterCard ESEC Refund Policy Note All cancellations must be in writing and emailed or mailed to ESE[ before refund will be Issued bull 100 Refund four (4) weeks prior to start date bull 50 Refund Between two (2) and four (4) weeks prior to start date bull No Refund After (2) weeks prior to start dete bull There will be a $10 charge 00 ali credit card refunds due to charges Incurred by ESEC

ESEC Emergencv Services S~Ialtt updted fo4rc~ 11 2013Phone 3119887703700 N High High School Rd DIego 11 Wts lt~i ~i~ ~~~l~Fa 3172487931

Indianapolis Indiana 46241 Qutstton5JCommentsl _FHltL=

httpwwwwaynek12inusleseccpat_ faqasp 31192013

APPLICANTS STATEMENT (Please Indicate that you have read and understand each paragraph of the

Applicants Statement by elJtclng youe Initials beside tach Pfragraczb)

I completed this application and confirm all Information In It is TRUE and COMPLETE to the best of my knowledge I understand that false misleading or omitted information may result In the rejection of my application the revocation of an offer of employment or discharge

I authorize Investfgatlon of all statements in this application to arrive at an employment decisIon I understand that an investigation may be made and Information may be obtained through Interviews with personal references and past employsrs a credit check a criminal history check andor a drivers record check This Inquiry may Include Information as to among other things my charecter general reputation and personal characteristics as well as Information about my work performance and workplace conduct I consent to this Investigation and to the consideration of any statements of references former employers or others that are given in response to the Inquiry If the City decides to obtain a consumer credit report I understand that It will provide at my request the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of Information contained In suCh report

I release aU parties including but not limited to the City personal references and previous or current employers from liability for any Injury or damage that may result from their furnishing information concerning me or any action the City takes on the basis of such information

I understand that If I am offered a job as a condition of beginning my employment I may be required to undergo a physical examination and drug screen and I authorize any service provider or medical facility to furnish any medical Information with reference to me In conjunction with that examination and related considerations

____ I understand that all Individuals hired must produce certain documentation to verify their Identity and United States citizen status or If aliens their legai authorization to work In the United States I understand that an offer of employment Is contingent upon my producing the required documentation withlnthe legal time period

I understand that this application is not and is not intended to be a contract of employment and that any resulting employment is not for a fixed period of time and Is terminable at any time and for any reason by me or by the City I further understand that statements that may be contained In policies practices handbooks or other material do not create a guarantee of employmerit and that the City has the right to modify amend or terminate policies practices benefits plans or other programs within the limits and requirements Imposed by law runderstand that no the City representative other than an officer has the authority to enter into any agreement for any specific period of time or to make any different agreement and that such agreement mu~t be In writing and signed by both parties to be binding

I confirm that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that the City offered to me nor am I In possession of nor will I at any time reveal to the City under any circumstances anyproprfetary or confidential Information that is the subject of any contract non-dlsclosure agreement or prior work relationship

Date ______________________ Signature of Applicant

THIS APPLICAnON WILL liQI BE CONSIDERED ACTIVE AFTER 60 DAYS

CPAT

You are Required to have a current CPAT Card at the time of your

application CPAT is the required physical agility test

CPAT Testing is done by ESEC Emergency Services

For more information on CPAT Testing contact

ESEC Emergency Services

400 N High School Road

Indianapolis IN 46214

(317) 988-7703

May 4th 2013 with be ((Kokomo Day at ESEC however you may take

the CPAT Test at ESEC any day offered prior to May 24th 2013

Wayne Township Emergency Services Education Center - CPAT F AQ Page 1 of 1

Schools amp Programsbull ISIC Emergenc) Services Education Center phone 317 966 7703 Wayne TownshIP

ESEC EMERGENCY SERVICES EDUCATION CENTER

SerVI((S amp links

Home About Us Courses amp Training Services Offered Conference Center Rental

Facilities Contact Us Registration Photo Gallery Vincennes University Offerings

CPATmiddot Frequently Asked Questions What Is the renon for waiting 8 weeks after Orientation to test The 6 week waiting period is set by the International Association of Firefighters nil association feels the 6 week period bull suffiCient amount of time for anyone to prepare themselves property to pass the physical ability test

Can I waive the B week waiting periOd Yes This Is your choice However you will Ill giving UP all your Dractice sessions and must sign a waiver the day you take tile test

Can I practice after I have attended Orientation and before I test Yes you may practice on any of our scheduled OrientationTest dates at no charge Two (2) timed test dates will be made available between your Orientation and Test date Practice is held from 745 AM 6JO AM on all dates we are at the [PAT facility

Ciln I take the CPAT test the same day that I attend Orlentation7 We do not recommend this However if this is your choice you can do so by registering for your Orientation date and sending an email reQuestinq a test appOintment time to be set up directly after Orientation is completed You will receive a confirmation email

What happens if I fail the test You may re-test as many time as you would like The retest tost S $6000 You can register on-line by clOSing out of this wmdow and clicking on [PAT Re-test or Renew CPAT Card You will select the date you want to re-test then you will receve an email with the apPOintment time available for the date of your choice

How long does the CPAT card lut7 Expiration of CPAT cards are up to each Individual Fire Dept However most Departments accept the CPAl card for one year

How long doe the Orientation last You need to arrive on time Orientation does not last long at all You wiflilot be there longer than 1 hour

How should I dreSf for Orientation Dress casual you Will not be going through the events at Orientation unless you want to try it after you have completed Orientation

When Orientation and Telting I on the Ame day I dont have to go through Orientation a 2nd time do I When ~ou show up to the CPAT facility yOU will be aske~ Are you here for Orientation or for Testing The Orientation group will De sent one direction and the Test group will be sent another direction

How should I dress for the CPAT Tn You must wear long pants (Short pants are not allowed) You must wear closed toe shoes such as tennis shoes (No open toed shoes are allowed)

How long will I be there for the CPAT test and should I brin9 anythln9 with me You will be given an appOintment time to test Test aPPOintments are scheduled in two hour time Increments You shOuld not be there any longer than 2 hours 10 minutes and 20 seconds after your scheduled time Please dress comfortably for the test and bring your identification With you

ESEC accept Cash CheckS Visa ilnd MasterCard ESEC Refund Policy Note All cancellations must be in writing and emailed or mailed to ESE[ before refund will be Issued bull 100 Refund four (4) weeks prior to start date bull 50 Refund Between two (2) and four (4) weeks prior to start date bull No Refund After (2) weeks prior to start dete bull There will be a $10 charge 00 ali credit card refunds due to charges Incurred by ESEC

ESEC Emergencv Services S~Ialtt updted fo4rc~ 11 2013Phone 3119887703700 N High High School Rd DIego 11 Wts lt~i ~i~ ~~~l~Fa 3172487931

Indianapolis Indiana 46241 Qutstton5JCommentsl _FHltL=

httpwwwwaynek12inusleseccpat_ faqasp 31192013

CPAT

You are Required to have a current CPAT Card at the time of your

application CPAT is the required physical agility test

CPAT Testing is done by ESEC Emergency Services

For more information on CPAT Testing contact

ESEC Emergency Services

400 N High School Road

Indianapolis IN 46214

(317) 988-7703

May 4th 2013 with be ((Kokomo Day at ESEC however you may take

the CPAT Test at ESEC any day offered prior to May 24th 2013

Wayne Township Emergency Services Education Center - CPAT F AQ Page 1 of 1

Schools amp Programsbull ISIC Emergenc) Services Education Center phone 317 966 7703 Wayne TownshIP

ESEC EMERGENCY SERVICES EDUCATION CENTER

SerVI((S amp links

Home About Us Courses amp Training Services Offered Conference Center Rental

Facilities Contact Us Registration Photo Gallery Vincennes University Offerings

CPATmiddot Frequently Asked Questions What Is the renon for waiting 8 weeks after Orientation to test The 6 week waiting period is set by the International Association of Firefighters nil association feels the 6 week period bull suffiCient amount of time for anyone to prepare themselves property to pass the physical ability test

Can I waive the B week waiting periOd Yes This Is your choice However you will Ill giving UP all your Dractice sessions and must sign a waiver the day you take tile test

Can I practice after I have attended Orientation and before I test Yes you may practice on any of our scheduled OrientationTest dates at no charge Two (2) timed test dates will be made available between your Orientation and Test date Practice is held from 745 AM 6JO AM on all dates we are at the [PAT facility

Ciln I take the CPAT test the same day that I attend Orlentation7 We do not recommend this However if this is your choice you can do so by registering for your Orientation date and sending an email reQuestinq a test appOintment time to be set up directly after Orientation is completed You will receive a confirmation email

What happens if I fail the test You may re-test as many time as you would like The retest tost S $6000 You can register on-line by clOSing out of this wmdow and clicking on [PAT Re-test or Renew CPAT Card You will select the date you want to re-test then you will receve an email with the apPOintment time available for the date of your choice

How long does the CPAT card lut7 Expiration of CPAT cards are up to each Individual Fire Dept However most Departments accept the CPAl card for one year

How long doe the Orientation last You need to arrive on time Orientation does not last long at all You wiflilot be there longer than 1 hour

How should I dreSf for Orientation Dress casual you Will not be going through the events at Orientation unless you want to try it after you have completed Orientation

When Orientation and Telting I on the Ame day I dont have to go through Orientation a 2nd time do I When ~ou show up to the CPAT facility yOU will be aske~ Are you here for Orientation or for Testing The Orientation group will De sent one direction and the Test group will be sent another direction

How should I dress for the CPAT Tn You must wear long pants (Short pants are not allowed) You must wear closed toe shoes such as tennis shoes (No open toed shoes are allowed)

How long will I be there for the CPAT test and should I brin9 anythln9 with me You will be given an appOintment time to test Test aPPOintments are scheduled in two hour time Increments You shOuld not be there any longer than 2 hours 10 minutes and 20 seconds after your scheduled time Please dress comfortably for the test and bring your identification With you

ESEC accept Cash CheckS Visa ilnd MasterCard ESEC Refund Policy Note All cancellations must be in writing and emailed or mailed to ESE[ before refund will be Issued bull 100 Refund four (4) weeks prior to start date bull 50 Refund Between two (2) and four (4) weeks prior to start date bull No Refund After (2) weeks prior to start dete bull There will be a $10 charge 00 ali credit card refunds due to charges Incurred by ESEC

ESEC Emergencv Services S~Ialtt updted fo4rc~ 11 2013Phone 3119887703700 N High High School Rd DIego 11 Wts lt~i ~i~ ~~~l~Fa 3172487931

Indianapolis Indiana 46241 Qutstton5JCommentsl _FHltL=

httpwwwwaynek12inusleseccpat_ faqasp 31192013

Wayne Township Emergency Services Education Center - CPAT F AQ Page 1 of 1

Schools amp Programsbull ISIC Emergenc) Services Education Center phone 317 966 7703 Wayne TownshIP

ESEC EMERGENCY SERVICES EDUCATION CENTER

SerVI((S amp links

Home About Us Courses amp Training Services Offered Conference Center Rental

Facilities Contact Us Registration Photo Gallery Vincennes University Offerings

CPATmiddot Frequently Asked Questions What Is the renon for waiting 8 weeks after Orientation to test The 6 week waiting period is set by the International Association of Firefighters nil association feels the 6 week period bull suffiCient amount of time for anyone to prepare themselves property to pass the physical ability test

Can I waive the B week waiting periOd Yes This Is your choice However you will Ill giving UP all your Dractice sessions and must sign a waiver the day you take tile test

Can I practice after I have attended Orientation and before I test Yes you may practice on any of our scheduled OrientationTest dates at no charge Two (2) timed test dates will be made available between your Orientation and Test date Practice is held from 745 AM 6JO AM on all dates we are at the [PAT facility

Ciln I take the CPAT test the same day that I attend Orlentation7 We do not recommend this However if this is your choice you can do so by registering for your Orientation date and sending an email reQuestinq a test appOintment time to be set up directly after Orientation is completed You will receive a confirmation email

What happens if I fail the test You may re-test as many time as you would like The retest tost S $6000 You can register on-line by clOSing out of this wmdow and clicking on [PAT Re-test or Renew CPAT Card You will select the date you want to re-test then you will receve an email with the apPOintment time available for the date of your choice

How long does the CPAT card lut7 Expiration of CPAT cards are up to each Individual Fire Dept However most Departments accept the CPAl card for one year

How long doe the Orientation last You need to arrive on time Orientation does not last long at all You wiflilot be there longer than 1 hour

How should I dreSf for Orientation Dress casual you Will not be going through the events at Orientation unless you want to try it after you have completed Orientation

When Orientation and Telting I on the Ame day I dont have to go through Orientation a 2nd time do I When ~ou show up to the CPAT facility yOU will be aske~ Are you here for Orientation or for Testing The Orientation group will De sent one direction and the Test group will be sent another direction

How should I dress for the CPAT Tn You must wear long pants (Short pants are not allowed) You must wear closed toe shoes such as tennis shoes (No open toed shoes are allowed)

How long will I be there for the CPAT test and should I brin9 anythln9 with me You will be given an appOintment time to test Test aPPOintments are scheduled in two hour time Increments You shOuld not be there any longer than 2 hours 10 minutes and 20 seconds after your scheduled time Please dress comfortably for the test and bring your identification With you

ESEC accept Cash CheckS Visa ilnd MasterCard ESEC Refund Policy Note All cancellations must be in writing and emailed or mailed to ESE[ before refund will be Issued bull 100 Refund four (4) weeks prior to start date bull 50 Refund Between two (2) and four (4) weeks prior to start date bull No Refund After (2) weeks prior to start dete bull There will be a $10 charge 00 ali credit card refunds due to charges Incurred by ESEC

ESEC Emergencv Services S~Ialtt updted fo4rc~ 11 2013Phone 3119887703700 N High High School Rd DIego 11 Wts lt~i ~i~ ~~~l~Fa 3172487931

Indianapolis Indiana 46241 Qutstton5JCommentsl _FHltL=

httpwwwwaynek12inusleseccpat_ faqasp 31192013

-- --

f

CPATREGISTRATION FORM PRINI THIS PAGE

Complete information and FAX with credit card information or mail payment by check to ESEC PI I I Iease print c early - thanks

IDate ofClass II I INamebullbull II IIStreet Address II IICity State and Zip Code I I Area Code and Phone NumberH

IIIE-mail addressmiddotshy II I Fire Department requesting card I I

TlmtdPractice Immediately Re[ufld Pollc tiJE 11 ~9nerlIlioll~ mDl be in wrilillg and ~middotmailed or mailed 10 ESE(

bftore rdund will be ISSUflL (ollowing CPAT Orientation

Yes No bull 100 RdDnd four (4) wee prior to Iare date Timed Practice -- Test - shy middot 50 rerund iJtlwren two (1) and COllr (4) wek~ prior to Slart dalt

bull No Refund rltr two mweek IIrior 10 tart dalt

I Please select one Visa D MCD I Orientation or Renew Circl~ (111 pkaM

Course Cost S13000 [rr Orienttlfirm 1 timed prrtCfie~ Iml fI~I1

RENEWRECEttflFIC A nONRETEST cost is i601QQ

Icard I

IName on Card

IExpiration Date

I I IISignature I

Check _____

Mail to ESEC Registration 700 N High School Road Indianapolis IN 46214

FAX (317)-248-7931

Questions Please call (317)-988-7703

For ESEC Use Only

Confinnation Invoice

CPAT__ConfLtr __lnv Rcvd Pmt Print Strnt __Print Inv __

91712012

Please date and sign below that application was received and it included the following

__ Notice to Applicants

__ CPAT (Candidate Physical Ability Test) Information (3 pages)

__ Basic Qualifications (2 pages)

__ Cadet Firefighter Job Description (3 pages)

__ Environmental Factors that affect Job Functions for Firefighters (2 pages)

__ Applicant Information Summary (21 pages)

__ Authorization and Release Form (2 pages)

Date Signature

Thank Youl

Dear Applicant

The City of Kokomo accepts applications for Firefighters on an on-going basis Some of the basic qualifications and selection procedures consist of but are not limited to the following

1 In order to be eligible to apply for appointment to the Kokomo Fire Department an applicant must be a resident citizen of the United St~tes and must be a resident of Howard County Indiana or contiguous county at the time of appointment

2 Applicant must have reached his of her tw~nty-first (21) birthday but shall not have reached his or her thirty-sixth (36) birthday as set forth by Indiana Code 36-8-4-7

3 Applicant shall be a high school graduate as evidenced by a diploma issued by a high school accredited by the department or agency of a State authorized to aea-edit high schools An equivalency diploma (GED) jssued by such as accredited high school is acceptable

4 Must be able to acquire ~ valid Indiana drivers license

5 A dishonorable discharge from the military service shall disqualify the applicant

6 Applicants receiving compensation or pension benefits from military service are not disqualified from applying

7 The applicant shall also possess the following Vision Standards Corrected Vision - Bjnocular vision no worse than 20130 worst eye vision no worse than 2050 Uncorrected Vision - binoallar vision no worse than 201100 (with the exception fGr-long-term successful users of soft contact lenses) Peripheral Vision - uncorrected field of vision no worse than 140 degrees in the horizontal meridian In each eye The applicant shall aJso have the ability to distinguish the corors of red green and amber and shall have no pathology of the eyes (Minimum standards set forth by Indiana Law Enforcement Training 8oardand the Kokomo Fire Pension Board)

8 Applicants shall not have been convicted of a felony

GREG GOODNIGHT MAYOR aty Hall 100 Soutll Ualoa Street

KokomoIDdiabullbull 46901 Fu(765)456middot7572

Qualification RequirementsPage 2

9 Must be able to successfully complete both the extensive physical agility test and written aptitude examinatfon

10 Must be able to passa thorough background investfgation and provide the Kokomo Fire Department with a Criminal History check through the Indiana State Police Central Records Division

11 Must submit tomiddot an oral Interview

12 No illegal delivery of drugs for monetary or material gain

13 No Illegal use of any type of drugs two (2) years prior to applying

All applicants are required to assist and cooperate in obtaining past employment records or personal history information

Failure to cooperate may be considered cause for disqualification

If it is found that you have falsified your application you will be automatically eliminated or if employed may be grounds for immediate discharge

Applications and test results become the exclusive property of the City of Kokomo

I have read and understand the above statement

Signature of Applicant

Toe Kokomo Fire Department will conduct testing Any position vacated between the prescribed testing times will be filled from the eligibility list

lliE CITY OF KOKOMO IS AN EQUAL OPPORTUNITY EMPLOYER

occasionally exposed to toxic or caustic chemicals extreme heat or cold and is occasionally at risk of radiation and vibration exposure The employee is frequently exposed to outdoor weather conditions and to wet or humid conditions TIle noise level is usually moderate characteristics described here are representative of those an employee encounters while performing the essential functions of this job

SALARY This job description is not intended as an employment contract nor is it intended to describe all duties someone in tbis position mfty be required to perform

~ ~

((~fii r~ ~~

f

l

I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

Please date and sign below that application was received and it included the following

__ Notice to Applicants

__ CPAT (Candidate Physical Ability Test) Information (3 pages)

__ Basic Qualifications (2 pages)

__ Cadet Firefighter Job Description (3 pages)

__ Environmental Factors that affect Job Functions for Firefighters (2 pages)

__ Applicant Information Summary (21 pages)

__ Authorization and Release Form (2 pages)

Date Signature

Thank Youl

Dear Applicant

The City of Kokomo accepts applications for Firefighters on an on-going basis Some of the basic qualifications and selection procedures consist of but are not limited to the following

1 In order to be eligible to apply for appointment to the Kokomo Fire Department an applicant must be a resident citizen of the United St~tes and must be a resident of Howard County Indiana or contiguous county at the time of appointment

2 Applicant must have reached his of her tw~nty-first (21) birthday but shall not have reached his or her thirty-sixth (36) birthday as set forth by Indiana Code 36-8-4-7

3 Applicant shall be a high school graduate as evidenced by a diploma issued by a high school accredited by the department or agency of a State authorized to aea-edit high schools An equivalency diploma (GED) jssued by such as accredited high school is acceptable

4 Must be able to acquire ~ valid Indiana drivers license

5 A dishonorable discharge from the military service shall disqualify the applicant

6 Applicants receiving compensation or pension benefits from military service are not disqualified from applying

7 The applicant shall also possess the following Vision Standards Corrected Vision - Bjnocular vision no worse than 20130 worst eye vision no worse than 2050 Uncorrected Vision - binoallar vision no worse than 201100 (with the exception fGr-long-term successful users of soft contact lenses) Peripheral Vision - uncorrected field of vision no worse than 140 degrees in the horizontal meridian In each eye The applicant shall aJso have the ability to distinguish the corors of red green and amber and shall have no pathology of the eyes (Minimum standards set forth by Indiana Law Enforcement Training 8oardand the Kokomo Fire Pension Board)

8 Applicants shall not have been convicted of a felony

GREG GOODNIGHT MAYOR aty Hall 100 Soutll Ualoa Street

KokomoIDdiabullbull 46901 Fu(765)456middot7572

Qualification RequirementsPage 2

9 Must be able to successfully complete both the extensive physical agility test and written aptitude examinatfon

10 Must be able to passa thorough background investfgation and provide the Kokomo Fire Department with a Criminal History check through the Indiana State Police Central Records Division

11 Must submit tomiddot an oral Interview

12 No illegal delivery of drugs for monetary or material gain

13 No Illegal use of any type of drugs two (2) years prior to applying

All applicants are required to assist and cooperate in obtaining past employment records or personal history information

Failure to cooperate may be considered cause for disqualification

If it is found that you have falsified your application you will be automatically eliminated or if employed may be grounds for immediate discharge

Applications and test results become the exclusive property of the City of Kokomo

I have read and understand the above statement

Signature of Applicant

Toe Kokomo Fire Department will conduct testing Any position vacated between the prescribed testing times will be filled from the eligibility list

lliE CITY OF KOKOMO IS AN EQUAL OPPORTUNITY EMPLOYER

occasionally exposed to toxic or caustic chemicals extreme heat or cold and is occasionally at risk of radiation and vibration exposure The employee is frequently exposed to outdoor weather conditions and to wet or humid conditions TIle noise level is usually moderate characteristics described here are representative of those an employee encounters while performing the essential functions of this job

SALARY This job description is not intended as an employment contract nor is it intended to describe all duties someone in tbis position mfty be required to perform

~ ~

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I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

Dear Applicant

The City of Kokomo accepts applications for Firefighters on an on-going basis Some of the basic qualifications and selection procedures consist of but are not limited to the following

1 In order to be eligible to apply for appointment to the Kokomo Fire Department an applicant must be a resident citizen of the United St~tes and must be a resident of Howard County Indiana or contiguous county at the time of appointment

2 Applicant must have reached his of her tw~nty-first (21) birthday but shall not have reached his or her thirty-sixth (36) birthday as set forth by Indiana Code 36-8-4-7

3 Applicant shall be a high school graduate as evidenced by a diploma issued by a high school accredited by the department or agency of a State authorized to aea-edit high schools An equivalency diploma (GED) jssued by such as accredited high school is acceptable

4 Must be able to acquire ~ valid Indiana drivers license

5 A dishonorable discharge from the military service shall disqualify the applicant

6 Applicants receiving compensation or pension benefits from military service are not disqualified from applying

7 The applicant shall also possess the following Vision Standards Corrected Vision - Bjnocular vision no worse than 20130 worst eye vision no worse than 2050 Uncorrected Vision - binoallar vision no worse than 201100 (with the exception fGr-long-term successful users of soft contact lenses) Peripheral Vision - uncorrected field of vision no worse than 140 degrees in the horizontal meridian In each eye The applicant shall aJso have the ability to distinguish the corors of red green and amber and shall have no pathology of the eyes (Minimum standards set forth by Indiana Law Enforcement Training 8oardand the Kokomo Fire Pension Board)

8 Applicants shall not have been convicted of a felony

GREG GOODNIGHT MAYOR aty Hall 100 Soutll Ualoa Street

KokomoIDdiabullbull 46901 Fu(765)456middot7572

Qualification RequirementsPage 2

9 Must be able to successfully complete both the extensive physical agility test and written aptitude examinatfon

10 Must be able to passa thorough background investfgation and provide the Kokomo Fire Department with a Criminal History check through the Indiana State Police Central Records Division

11 Must submit tomiddot an oral Interview

12 No illegal delivery of drugs for monetary or material gain

13 No Illegal use of any type of drugs two (2) years prior to applying

All applicants are required to assist and cooperate in obtaining past employment records or personal history information

Failure to cooperate may be considered cause for disqualification

If it is found that you have falsified your application you will be automatically eliminated or if employed may be grounds for immediate discharge

Applications and test results become the exclusive property of the City of Kokomo

I have read and understand the above statement

Signature of Applicant

Toe Kokomo Fire Department will conduct testing Any position vacated between the prescribed testing times will be filled from the eligibility list

lliE CITY OF KOKOMO IS AN EQUAL OPPORTUNITY EMPLOYER

occasionally exposed to toxic or caustic chemicals extreme heat or cold and is occasionally at risk of radiation and vibration exposure The employee is frequently exposed to outdoor weather conditions and to wet or humid conditions TIle noise level is usually moderate characteristics described here are representative of those an employee encounters while performing the essential functions of this job

SALARY This job description is not intended as an employment contract nor is it intended to describe all duties someone in tbis position mfty be required to perform

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l

I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

Qualification RequirementsPage 2

9 Must be able to successfully complete both the extensive physical agility test and written aptitude examinatfon

10 Must be able to passa thorough background investfgation and provide the Kokomo Fire Department with a Criminal History check through the Indiana State Police Central Records Division

11 Must submit tomiddot an oral Interview

12 No illegal delivery of drugs for monetary or material gain

13 No Illegal use of any type of drugs two (2) years prior to applying

All applicants are required to assist and cooperate in obtaining past employment records or personal history information

Failure to cooperate may be considered cause for disqualification

If it is found that you have falsified your application you will be automatically eliminated or if employed may be grounds for immediate discharge

Applications and test results become the exclusive property of the City of Kokomo

I have read and understand the above statement

Signature of Applicant

Toe Kokomo Fire Department will conduct testing Any position vacated between the prescribed testing times will be filled from the eligibility list

lliE CITY OF KOKOMO IS AN EQUAL OPPORTUNITY EMPLOYER

occasionally exposed to toxic or caustic chemicals extreme heat or cold and is occasionally at risk of radiation and vibration exposure The employee is frequently exposed to outdoor weather conditions and to wet or humid conditions TIle noise level is usually moderate characteristics described here are representative of those an employee encounters while performing the essential functions of this job

SALARY This job description is not intended as an employment contract nor is it intended to describe all duties someone in tbis position mfty be required to perform

~ ~

((~fii r~ ~~

f

l

I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

occasionally exposed to toxic or caustic chemicals extreme heat or cold and is occasionally at risk of radiation and vibration exposure The employee is frequently exposed to outdoor weather conditions and to wet or humid conditions TIle noise level is usually moderate characteristics described here are representative of those an employee encounters while performing the essential functions of this job

SALARY This job description is not intended as an employment contract nor is it intended to describe all duties someone in tbis position mfty be required to perform

~ ~

((~fii r~ ~~

f

l

I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

((~fii r~ ~~

f

l

I I I I I

POSITION CADET FIREFIGHTER DEPARTMENT KOKOMO FIRE DEPARTMENT WORK SCHEDULE 800am - 800am (assigned platoon)

DATE WRITTEN 1184 STATUS Full - Time DATE REVISED 105 FLSA STATUS Non ~ Exempt

GENERAL STATEMENT OF DUTIES Probationary Firefighters will participate in comprehensive recruit training that will last approximately six (6) weeks-Monday through Friday from 8am to 4pm The employee will remain on probation for a period of one year with a supervisors evaluation being completed every month Upon completion of the six week recruit training the employee will engage directly in firefighting hazardous materials response technical rescue and emergency medical service and prevention activities to protect the public property and the environment The employee will assfst in routine maintenance and repairs of Department equipment and stations Performs all work tasks assigned by the Fire Chief through the chain of command

DISTINGUISHING FEATURES OF THE CLASS The employee is responsible for performing hazardous tasks under emergency conditions Work involves the wearing of protective clothing and self-contained breathing apparatus while in close contact with toxic gases corrosive materials explosive mixtures or radioactive substances The probationary firefighter must readily become familiar and proficient with modem firefighting hazardous materials response technical rescue emergency medical service and prevention methods and procedures Prior to completion of the probationary year the employee wiil be evaluated and permanent status or termination will be recommended The work requires strict adherence to Department rules and regulations and standard operating procedures Superiors make assignments of specific tasks and indicate methods and procedures to be followed Emergency tasks are performed under close supervision and the employee will remain in contact with their supervisor at all times while on the emergency scene

ESSENTIAL DUTIESI (Other duties as assigned) bull Must successfully complete extensive six week recruit training program bull Performs fire suppression procedures such as advancing hoselines extinguishing

fires forcible entry search and rescue ventilation and salvage and overhaul bull Performs hazardous materials remediation procedures at the Operations level bull Performs technical rescues at the Opemtions level bull Performs emergency medical service as a certified First Responder bull Drives and operates apparatus and equipment in lieu of DriverOperator bull Makes periodic pre-fire planning inspections of places of public gathering and

businesses bull Checks fire hydrant locations and operation bull Participates in routine training sessions and drills in fire fighting hazardous materials

response technical rescue and emergency medical service bull Performs routine maintenance and repairs of stations station grounds and equipment bull ADHERES TO TRAFFIC REGULATIONS AND SAFETY STANDARDS

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

I QUALIFICATION REQUIREMENTS To perform this job successfully an individual must be able to perform each essential duty satisfactorily and must maintain regular attendance The requirements listed below are representative of the knowledge skill andor ability required

EDUCATION andor EXPERIENCE High school diploma or general education degree (GED)

MATHEMATICAL SKILLS Ability to apply concepts such as fractions percentages ratios and proportions to practical situations

LANGUAGE SKILLS Ability to read and interpret documents such as safety rules operating and maintenance instruction and procedure manuals Ability to keep simple records and make reports Ability to speak effectively before groups or employees

REASONING ABILITY Ability to apply common sense understanding to carry out instructions furnished in written oralbullor diagram fonn Ability to deal with problems involving several concrete variables in standardized situations

OTHER REQUIRED KNOWLEDGE SKILLS AND ABILITIES Aptitude for mechanical work strength agility coordination and the ability to do prolonged physical and mechanical work under adverse conditions a high degree of manipulative skill cooperativeness and the ability to get along with other Must obtain and maintain certifications for Firefighter Jill HazMat Operations and First Responder within the first year of employment and Emergency Medical Technician within the first two years ofemployment

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of

this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

While performing the duties of this job the employee is regularly required to sit stand and walk talk or hear use hands to finger handle or feel and reach with their hands and anns The employee is frequently required to climb or balance stoop kneel crouch or cnlwl and taste or smell

The employee must frequently lift andor move up to 100 pounds Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and the ability to adjust focus

WORK ENVIRONMENT The work environment While perfonning the duties of this job the employee is frequently exposed to fumes or airborne particles and toxic or caustic chemicals and frequently works near moving mechanical parts The employee is

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS

The essential job functions for a firefighter are performed in and affected by the following environmental factors A firefighter must

1 Operate both as a member of a team and independently at incidents of uncertain duration

2 Spend extensive time outside exposed to the elements

3 Experience frequent transition from hot to cold and from humid to dry atmospheres

4 Tolerate extreme fluctuations in temperature and performphysically demanding work in hot (up to 400 degrees F) humid (up to 100) atmospheres while wearing equipmentthat significantly impairs body cooling mechanisms

5 Work in wet icy or muddy areas

6 Perform a variety of tasks on slippery hazardous surfaces such as on roof tops or from ladders

7 Work in areas where sustaining traumatic or thermal injury is possible

8 Must wear personal protective equipment to prevent face exposure to carcinogenic dusts such as asbestos toxic substances such as hydrogen cyanide acids carbon monoxide or organic solvents either through inhalation or skin contact

9 Must wear personal protective equipment to prevent face exposure to infectiOUS agents such as hepatitis B or HIV

10 Perform complex tasks during life-threatening emergencies

11 Work for long periods of time requiring sustained physical activity and intense concentration

12 Face life or death decisions during emergency conditions

13 Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims

14 Make rapid transitions from rest to near maximal exertion without warm-up periods

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS FOR FIREFIGHTERS Page 2

15 Operate in environments of high noise poor visibilitylimited mobility at heights and in enclosed or confined spaces

16 Use manual or power tools in the performance of duties

17 Rely on senses of sight hearing smell and touch to help determine the nature of the emergency maintain personal safety and make critical decisions in confused chaotic and potentially life threatening environments

18 Wear personal protective equipment that weighsapproximately 50 pounds while performing the essential functions of their job

19 Perform physically demanding work while wearing positive pressure breathing equipment with 15 inches water column resistance to exhalation at a flow of 40 liters per minute

20 Be able to communicate with people effectively

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

NAME - PRINT OR TYPE ___________________________________

SOCIAL SECURITY NUMBER ________________________________

DATE OF BIRTH

APPLICANT INFORMATION SUMMARY

KOKOMO FIR E D EPA R T M E M T

CITY BUILDING 100 SOUTH UNION

KOKOMO INDIANA 46901

STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY POLICY

The Fire Department is an Equal Employment Opportunity Employer and

will accept applications hire qualified applicants administer all

terms and conditions of employment and make available all benefits and

compensations of employment without regard to race color creed

religion sex national origin or disability status

All applicants and e_ployees are protected from discrimination because

of political affiliation and from coercion for partisan political

purposes

No question on this report is intended to secure information to be used

for unlawful discrimination

PAGE 1

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

I PERSONAL HISTORY

A NAME IN FULL (last first middle)

B SOCIAL SECURITY NUMBER

C List all other names you used including nicknames If female furnish maiden name If you have ever used any last name other than your true name during what period and under what circumstances were these names used If you have ever legally changed your name give date place and court (This information is being collected to assist the department in conducting a thorough background investigation ie felony conviction check)

D BIRTH DATE (month day year)

BIRTH PLACE (city state)

Include a copy of your Birth Certificate This will be used to verify your age for statutory requirements and pension purposes (See next page)

E ARE YOU A US CITIZEN YES NO

PAGE 3

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ATTACH A COpy OF YOUR BIRTH CERTIFICATE TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 4

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

II FAMILY HISTORY

List all family members (living or deceased) in the following order parents step-parents foster parents guardians brothers sisters spouse children in-laws ex-spouses (if living)

Relationship Present addressZip Code

PAGE 5

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ATTACH COPIES OF YOUR MARRIAGE CERTIFICATE(S) AND DIVORCE DECREE(S) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE - NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 6

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

III RESIDENCES

A Present residence (number street city county state zip code telephone if apartment include name and location of complex)

B List chronologically (most current first) all of your residences in the past ten years Include addresses while attending school if away from home and ALL military addresses including off base locations Also towns or cities that are located in the immediate vicinity of military complexes If apartment include name and location of complex

Date StateFrom To Number Street City Zip Code

IV EDUCATION

List all schools attended at the High School level and above copies of all transcripts and diplomasdegrees

Include

High Schools

Years Attended From To School Address

DegreeDiploma

CollegesUniversities

Graduate Schools

Other Vocational Etc

PAGE 7

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ATTACH COPIES OF HIGH SCHOOL TRANSCRIPT OF GRADES AND DIPLOMA TO THE BACK OF THIS PAGE

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

ATTACH COPIES OF COLLEGE TRANSCRIPT OF GRADES AND DIPLOMADEGREE TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 8

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

V EMPLOYMENT RECORD

List chronologically (most current first) all ~ormer and current employers Include full-time part-time and temporaryseasonal work and all periods of unemployment Present employers will be contacted prior to any appointment Make sure all phone numbers are correct including extension numbers

1 Employment Date - From ___________________ To ___________________

Name of Company ~------------------------------__----------------------- shyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor _______________________________________________________

Final Salary __~--__-------------------------------------------------- shyReason For Leaving _______________________________________________________

2 Employment Date - From __________________ _ To

Name of Company ~-------------------------------------------------------shyAddress amp Zip CodePhone Number amp Extension ________________________________________________ Position HeldName of Superv~i-s-o-r-------------------------------------------------------shy

Final Salary __~__--__----------------------------------------------- shyReason For Leaving ______________________________________________________

3 Employment Date - From __________________ To __________________

Name of Company ~------__----------------------------------------------- shyAddress amp Zip CodePhone Number amp Exte-n-s~i~o-n-------------------------------------------------shy

Position Held ~----__------__----------------------------------------- shyName of Supervisor Final Salary Reason For Leaving

4 Employment Pate - From __________________ To Name of Company ~-----------------------------------------------------shyAddress amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary __~--------------------------------------------------------shyReason For Leaving ______________________________________________________

PAGE 9

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

V EMPLOYMENT RECORD (continued)

5 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

6 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal SalaryReason For Leaving

To

7 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

8 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of Supervisor Final Salary Reason For Leaving

To

9 Employment Date - From Name of Company Address amp Zip Code Phone Number amp Extension Position Held Name of SupervisorFinal Salary Reason For Leaving

To

PAGE 10

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

V EMPLOYMENT RECORD (continued)

10 Employment Date - From __________________ To Name of CompanyAddress amp Zip Code Phone Number amp Extension Position HeldName of Supervisor ______________________________________________________ ~-------------------------------------------------------shyFinal SalaryReason For Le-a-v~i-n-g-----------------------------------------------------shy

11 Employment Date - From ___________________ To Name of CompanyAddress amp Zip Co~d-e----------------------------------------------------shyPhone Number amp Extension ______________________________________________ Position HeldName of Supervisor ____________________________________________________ ~-------------------------------------------------------shy

Final Salary __~-------------------------------------------------------shyReason For Leaving

12 Employment Date - From To Name of CompanyAddress amp Zip Co~d-e-middot---------------------------------------------------shyPhone Number amp Extension Position Held

~--------------------------------------------------------shyName of Supervisor Final Salary __~----------__--__--------------------------------------- shyReason For Leaving ____________________________________________________

13 Any gaps in employment of more than six (6) months should be explained below

PAGE 11

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ATTACH A COpy OF YOUR RESUME TO THE BACK OF THIS PAGE

DO YOU WISH TO SUBMIT ONE Yes No

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 12

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

VI MILITARY SERVICE

A Have you ever served on active duty in the Armed Forces of the United States Yes No

Branch of Service

Dates of Active Duty (month day year)

Serial Number

B Are you currently or have you ever been a member of any United States Armed Forces Reserve or NationalState Guard Unit Yes No

If yes what is your reserve obligation (if any) unit and location (address city state zip code telephone)

C While in Military Service were you ever convicted of any offense (civil or military) Yes No

When Explain _____________________________________________________________

PAGE 13

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

ATTACH A COPY OF YOUR 00214 (DISCHARGE PAPERS) TO THE BACK OF THIS PAGE IF APPLICABLE IF NOT INDICATE NA (STILL DATE AND SIGN BELOW)

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

PAGE 14

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

VIII DRIVERS RECORD

A List all vehicle operators licenses you now hold or have held

Type (Drivers State of License ExpirationChauffeurs) Issuance Number Date Restrictions

B List all vehicle accidents you have had in the past 3 years

Did you receive Date Location Description a Citation

C List all traffic citations you have received in the past 3 years

Date Location Charge

D Has your Drivers License ever been suspended or revoked

Yes No

If yes explain

IX ARRESTFELONY CONVICTION RECORD

A Have you ever been arrested or detained by a law enforcement agency Yes No _______

If yes provide date(s) place(s) and disposition(s) on supplemental page

NO APPLICANT WILL BE AUTOMATICALLY REJECTED BECAUSE OF AN ARREST RECORD THIS INFORMATION IS BEING OBTAINED ONLY TO ASSIST IN COMPLETION OF A BACKGROUND INVESTIGATION

PAGE 15

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

IX ARRESSTFELONY CONVICTION RECORD (continued)

B Have you ever been convicted of a felony Yes____ No---shy

X REFERENCES

List three to five current references (other than relatives and former or current employers)

1 Name

Address amp Zip Code

Phone Number during day

Occupation Length of Time Known

2 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

3 Name

Address amp Zip Code

Phone Number during day

Occupation

Length of Time Known

Page 16

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

------------------------------------------------------

----------------------------------------

4 Name

Address amp Zip Code ______________________

Phone Number during day ________________________________

Occupation________________________________

Length of Time Known ___________________________

5 Name

Address amp Zip Code ______________________

Phone Number during day _____________________________

Occupation___________________________________

Length of Time Known ______________________________

XI Is there any information not mentioned in this Summary that may reflect upon your

Suitability to perform the duties you may be called upon to perform or that might require

Further explanation If so explain

XII Have you applied for the position of Kokomo Firefighter before __Yes No

If so when ________________________

Page 17

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

TAPE OR GLUE TWO (2) PHOTOGRAPHS TO THIS PAGE (1) FULL LENGTH AND (1) HEAD amp SHOULDER

PLEASE DATE AND SIGN BELOW THANK YOU

DATE SIGNATURE

Page 18

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

XIII APPLICANT CHECK LIST

Please use the following list as a guide in completing your application Use copies only not originals and attach to the page indicated Date and sign all pages where indicated

__ Birth Certificate (copy only) - page 4

__ Marriage Certificate if applicable (copy only) - page 6

__ Divorce Decree if applicable (copy only) - page 6

__ High School and College transcripts and diplomas (copies only) - page 8

__ 00214 Form if applicable (copy only) - page 14

__ Two photographs (1) full length amp (1) head and shoulder- page 20

__ Full names ampaddresses of family members (mother father step-parents foster-parents Guardians brothers sisters spouse children in-laws ex-spouses) - page 5

__ Addresses and dates pertaining to all prior residences in the last ten years - page 7

__ Information pertaining to all present and former employers (dates names addresses amp phone numbers of Company) - pages 9 10 and 11

__ Dates of military active duty serial number and reserve obligation - page 13

__ Type Expiration date number and restrictions relating to Drivers license - page 16

__ Dates locations descriptions of any vehicle accident in the last three years Note any Citations

__ The date place charge and the disposition of any arrest (AdultJuvenile) localnon-IocalshyPage 16

__ Information relating to three to five personal references (names address telephone number during the day occupation length of time known amp zip code) References shall not include Relatives or formercurrent employers - pages 18 and 19

__ Zip Codes

PAGE 19

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

XIV SIGNATURE

Read the following statement carefully If you have any questions ask the interviewer before signing the form

I CERTIFY THAT THE INFORMATIONI N THIS FORM IS CORRECT AND COMPLETE TO THE

BEST OF MY KNOWLEDGE I REALIZE THAT MISREPRESENTATION OF FACTS IS CAUSE

FOR REJECTION OF MY APPLICATION OR DISMISSAL AFTER APPOINTMENT I

UNDERSTAND THAT FINAL EMPLOYEMENT IS CONTINGENT UPON SATISFACTORY

COMPLETION OF ALL PHASES OF THE APPLICANT SCREENING PROCESS

SIGNATURE OF APPLICANT DATE OF SIGNATURE

Subscribed and sworn to before me a Notary Public in the County of ______ State of

_______ this __day of _____ 20 __

Notary Public ____________

My commission Expires ________

XV REVIEW BY INTERVIEWER

A Reviewed by ____________________

B Date Reviewed ________- __________

Date Issued ________________________

Date Returned ___________________~___

PAGE 20

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

SUPPLEMENTAL PAGE

ADDITIONAL INFORMATION MAY BE PROVIDED BELOW

ANY CERTIFICATES SEMINARS WORKSHOPS OR OTHER INFORMATION YOU FEEL WOULD BE OF BENEFIT SHOULD BE ATIACHED TO THIS PAGE

PAGE 21

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

TO WHOM IT MAY CONCERN I am an applicant for a position with the Kokomo Fire Department The Department needs to thoroughly investigate my employment background and parsonal history to evaluate my qualifications to hold the position for which I have applied It Is In the publics Interest that all relevant Information concerning my personal and employment history be disclosed to the above Department

I hereby authorize any representaUve of the Kokomo Fire Department bearing this release to obtain any and all Information i1 your files pertaining to my employment records and I hereby direct you to release such Information upon request of the bearer I do hereby authorize a review of and full disclosure of aU records or any part thereof concerning myself by and to any duly authorized agent of the Kokomo Flra Department whether said records are of public private or confidential nature The Intent 0 this authorization Is to giVe my consent for full and complete disclosure I reiterate and emphasize that the Intent of this authorization Is to prOvide full and free access to the background and history of my personallfe for the specific purpose of pyrsulng a background InyestigaUon that may provide pertinent data for the Kokomo Fire oepartment to consider In determining my syltabliity for employment In that Department It Is mY specific Intent to provide access to personnel Information however personal or confidential It may tppear to be

I conent to your releae ofany and al public and private Information that you may have concerning me my WOIk ffICOId my background and reputation my military service records my educational records my financial statu my crfminal hltory record Inclucfng any amlst records any Information contaIned In any case either criminal or civil In which I presently have or have had an Interest attendance records polygraph examInations and any Internal affair Investigations and discipline Including any files that are deemed to be confidential

I hereby release you your organization and all others from liability or damages that any result from furnishing Information requested Including liability or damage pursuant to any state or federal law I hereby release you as custodian of such records of your organization Including its officers employees or related personnel both Individually and collectively from any and aliIability for damages ofwhatever kind which may at any time result to me my heirs family or associates because of compliance with this authorization and request to release information or any attempts to comply with It I direct you to release such Infoonatlon upon request of the duly authorized representatiVe oflbe Kokomo Fire Department regardless of any agreement I may haye made with you previously to the contrary The law enforcement organlzatioD requesting the information PYIJuant to this release may dlscontlnye processjOQ my application ifyoy refuse to disclose the InfoonaHoo requested

For and in consideration of the Kokomo Fire Departments acceptance and processing of my application for employment I agree to hold your organization Its agents and employees harmless from any and all claims and liability associated with my application for employment or In any way connected with the decision whether or not to employ me with the Kokomo Fire Department I understand that should Information of a serious criminal nature or regarding an outstanding Criminal andor civil warrant surface as a result of this Investigation such Information may be turned over to the proper authorities

GREG GOODNIGHT MAYOR City Ha1~ 100 South Uaioo SIrNt Fax (76S)4S6-7Sn Kokomo lDdilllamp 46901

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

-------------------------- -------------------------

I understand my rights under Title 5 United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights With the understanding that Information furnished will be used by the Kokomo Fire Department in conjunction with employment procedures

A photocopy or fax copy of this release form will be valid as an original thereof even though the said photocopy of fax copy does not contain an original writing of my signature

This waiver Is valid for a period of two yers from the date of my slgnature

Should there be any questions as to the validity of this release you may contact me at the address listed on this form

I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form

I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and empioyees from and against all clalmslosses and expenseslncludlng reasonable attorney fees arising out of or by reason of complying with this request

Signature Qncludlng maiden name if applicable) Date of Birth

Address Social Securfty Number

CltyStatelZlp Code Telephone Number

COUNTY__________________STATEOF__________

BEFORE ME a Notary Public In and for said County and State personally appeared----___ _~--__who acknowledged the execution of the foregoing Authortzation for Release of Information Agreement and who being first sworn under oath stated that the matters contained therein are true

WITNESS my hand and Notarial Seal this ___~day of 20__bull

NOTARY PUBUC (Sign In black Ink) NOTARY PUBLIC (Printed)

CITY COUNTY

My Commission Explras ____________

AUTHORIZATION FOR RELEASE OF INFORMATION AGREEMENT

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2

INSTRUCTIONS

1 Read each item carefully

2 This Summary must be typed or printed n~atly in ink

3 All items must be completed and necessary documentation included

4 If additional space is needed use the supplemental page at the end of this Summary referencing each item

5 The completed application must be returned to the City of Kokomos Personnel Department

POLICY REGARDING THE APPLICANT INFORMATION SUMMARY

1 Failure to comply with instructions and policy regarding this phaseof the Applicant Screening Process will result in the rejection of the application

2 Failure to accurately and truthfully complete this Summary will result in the rejection of the application

3 Applications will not be accepted without complete addresses phone numbers and zip codes

If you need assistance in completing this Summary please contact the Personnel Department 456-7470

USE ZIP CODES ON ALL ADDRESSES

PAGE 2