Application for Employment

Matlacha Pine Island Fire Control District

5700 Pine Island Road

Bokeelia, Fl 33922

Position Applied For:	Date:
Last Name First Middle	Social Security Number
Street Address
City, State & Zip Code
Home Phone Work/Message Phone E-mail Address

IF YOU CLAIM VETERAN’S PREFERENCE (FL STATUTE 295.07) YOU MUST SUBMIT CURRENT DOCUMENTATION WITH THIS APPLICATION.

Are you legally eligible for employment in USA? _______ Have you worked for us before? _______If yes, when? _________

Have you ever applied for a position here before? __________

List Relatives (R) and Friends (F) working for us. ___________________________________________________________________

If hired, do you have reliable means of getting to work? _______________ Are you willing to work over-time, if required? ________

Date of Birth ________________________ (Federal and State Law prohibits age discrimination.)

Have you ever been convicted of, or pled nolo contendere (con contest) of any offense(s) other than minor traffic violations? ______

If yes to the question above please attach explanation.

PERSONAL/BUSINESS REFERENCES: List complete mailing address and phone number (excluding Relatives and Employers listed employment section.

Name	Business
Address	Phone
City State Zip Code	Years Acquainted
Name	Business
Address	Phone
City State Zip Code	Years Acquainted
Name	Business
Address	Phone
City State Zip Code	Years Acquainted

APPLICANT’S CERTIFICATION AND AGREEMENT

I hereby authorize the Matlacha Pine Island Fire Control District to make any investigation of my education, work history and references.

I hereby certify that each response on this application and all other information I have furnished in applying for employment with the Matlacha Pine Island Fire Control District is true and correct. I agree that any misrepresentation by me in this application, including omission of information, will be sufficient cause for its cancellation or for dismissal from the Matlacha Pine Island Fire Control District service if I am employed.

__________________________________________________________________ __________________________

Signature Date

EDUCATION & SPECIAL TRAINING

Do you have a High School Diploma? ______________ G.E.D.? ______________ If not, highest grade completed: ________

Date Obtained _____________________________

Name and Address of School/Institution: __________________________________________________________________________

____________________________________________________________________________________________________________

List Colleges and Universities Attended: Name and Location

Total Hours Completed

Major/Minor Degree Field or Program of Study

Graduate Date (Year)

List Special Training (Business, Trade, Vocation, Armed Forces Schools, etc): Name and Location

Total Hours Completed

Course/Subject Taken

Certificate Received

Do you speak a foreign language(s)? _________________________ If so, what language(s)? _______________________________

OFFICE SKILLS/EXPERIENCE

Please rate level of experience for each listed below: 1 – Beginner User 2-Intermediate User 3-Advanced User

Personal Computer Skills: _____Windows _____ M.S. Outlook _____ M.S. Word _____ Word Perfect _____ M.S. Excel

_____ M.S. Access _____ Crystal Reports _____Internet Browsers ______________________________

Other ________________________________________________________________

Office Skills: _____ 10 Key Calculator _____ Dictation Machine Transcription _____ Typing ____________w.p.m.

_____ Shorthand ____________ w.p.m. _____ Data Entry __________________________________________program

Other: (explain) _______________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Note: Additional Comments/Responses may be continued on a separate sheet

EMPLOYMENT

This section must be completed in full, even if a resume is attached.

Beginning with your PRESENT or most recent employer, list all periods of employment and include self-employment and any military experience. Describe IN DETAIL your specific duties beginning with your primary duties. Attach additional sheets if necessary and please note if you used a different name.

May we contact your present employer? __________

Employer	Address
Your Official Job Title	Supervisor’s Name and Title
Dates Employed (Month and Year) From: To:	Beginning Salary $ Per	Ending Salary $ Per	Phone Number
Reason for Leaving
Describe you duties in detail

BETWEEN THESE JOBS (IF APPLICABLE): _____Unemployed _____ In School From (mo/yr)_______ To (mo/yr) ______

Employer	Address
Your Official Job Title	Supervisor’s Name and Title
Dates Employed (Month and Year) From: To:	Beginning Salary $ Per	Ending Salary $ Per	Phone Number
Reason for Leaving
Describe you duties in detail

BETWEEN THESE JOBS (IF APPLICABLE): _____Unemployed _____ In School From (mo/yr)_______ To (mo/yr) ______

Employer	Address
Your Official Job Title	Supervisor’s Name and Title
Dates Employed (Month and Year) From: To:	Beginning Salary $ Per	Ending Salary $ Per	Phone Number
Reason for Leaving
Describe you duties in detail

BETWEEN THESE JOBS (IF APPLICABLE): _____Unemployed _____ In School From (mo/yr)_______ To (mo/yr) ______

On reverse side please describe specific duties you have performed that may be applicable to the position(s) applied for.

EMPLOYMENT (Continued)

Dates- From/To:

Duties

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Duties

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Duties