Fire fighter I print or type please see instructions on back page application for employment




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CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)




FIRE FIGHTER I

PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE

APPLICATION FOR EMPLOYMENT










CAL FIRE 215 (REV. 12/14) Page


APPLICANT’S NAME (Last)

(First)

(M.I.)

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER




     

     

     

     




MAILING ADDRESS (Number)

(Street)

WORK TELEPHONE NUMBER




     

     

      




(City)

(County)

(State)

(Zip Code)

( Email Address)

HOME TELEPHONE NUMBER




     

     

   

     

      

      




ANSWER THE FOLLOWING QUESTIONS:







1.

Do you need reasonable accommodation to take an oral interview?





YES



NO




2.

Do your religious beliefs prevent you from taking an interview on Saturday?






YES



NO




3.

Do you meet the minimum age requirements of 18 years?






YES



NO







If you are not 18, please provide your date of birth: _____________________________
















4.

Have you ever: (If “YES”, give details in Item 5 below and refer to the Instructions for further details.)






















  1. Been dismissed or fired from a position for any reason?






YES



NO







  1. Resigned from or quit a position while under investigation or after being informed discipline would be taken against you or during an appeal from a disciplinary action?








YES




NO







  1. Been rejected or told you would not receive permanent or continued employment during any type of probationary or trial period on the job?






YES





NO

























5.
EXPLANATIONS







     







     







     







     







     




  1. EDUCATION: Please fill in the box that corresponds to the HIGHEST LEVEL of education completed, major (if applicable), and completion date. Please note that copies of transcripts and/or diploma MAY BE REQUIRED prior to appointment.

Personnel Use Only: [MAX] 10 _________________



AA/AS DEGREE


HIGH SCHOOL DIPLOMA/GED

COLLEGE UNITS COMPLETED

AA/AS DEGREE

BA/BS DEGREE




 YES

 NO

SEMESTER

QUARTER

Major:      

Major:      




Completion Date:      

     

     

Completion Date:      

Completion Date:      




  1. TRAINING: Please indicate which certification courses and/or emergency medical training you have successfully completed by marking “yes” or “no” for each course. Copies of current certifications WILL BE REQUIRED prior to appointment.

Personnel Use Only: [MAX] 45 _________________




A. CERTIFICATION COURSES

B. EMERGENCY MEDICAL COURSES







  1. STATE FIRE MARSHAL FIRE FIGHTER I

 YES

 NO

  1. CPR

 YES

 NO




  1. HAZ-MAT FIRST RESPONDER-OPERATIONAL

 YES

 NO

  1. PUBLIC SAFETY/FIRST AID

 YES

 NO




  1. CAL FIRE BASIC FIREFIGHTER

 YES

 NO

  1. FIRST RESPONDER

 YES

 NO




  1. CONFINED SPACE AWARENESS

 YES

 NO

  1. EMERGENCY MEDICAL TECHNICIAN

 YES

 NO













  1. PARAMEDIC

 YES

 NO




CERTIFICATION—IMPORTANTPLEASE READ BEFORE SIGNING—If not signed, this application may be rejected.




I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge. I further understand any false, incomplete, or incorrect statements may result in my disqualification from the selection process or dismissal from employment with the State of California. I authorize the employers and educational institutions identified on this application to release any information they may have concerning my employment or education to the State of California. Resumes will not be accepted in lieu of a completed application.




APPLICANT’S SIGNATURE



DATE SIGNED




APPLICANTS—DO NOT USE THIS SPACE BELOW—FOR OFFICIAL USE ONLY



FOR PERSONNEL USE ONLY








FLAG CODES:



FOR PERSONNEL USE ONLY





FS

CAT




CPR

HMFRO

CFBF

CSA

EMS

CDF FF EXP




REVIEWER SIGNATURE:




___

___



























APPLICANT’S NAME (Last)

(First)

(M.I.)

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

     

     

     

     

  1. FIREFIGHTING EXPERIENCE: List the applicable information specified below including classification title, location, employer, and months of experience. ALL INFORMATION WILL BE VERIFIED PRIOR TO APPOINTMENT. [MAX] 30 _________________
A). CDF FIREFIGHTING EXPERIENCE

Include CDF firefighting experience only (i.e., Fire Fighter I, Conservation Camp, Fire Center)

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

CDF UNIT

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

CDF UNIT

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     
B.) FULL-TIME NON-CDF FIREFIGHTING EXPERIENCE

Include full-time firefighting experience with other organizations (i.e., City, County, USFS, BLM, or National Park Service, etc.)

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     




APPLICANT’S NAME (Last)

(First)

(M.I.)

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

     

     

     

     

III. FIREFIGHTING EXPERIENCE, CONTINUED:
B.) FULL-TIME NON-CDF FIREFIGHTING EXPERIENCE

Include full-time firefighting experience with other organizations (i.e., City, County, USFS, BLM, or National Park Service, etc.)

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     
C.) PAID CALL, VOLUNTEER AND/OR RESERVE FIREFIGHTING EXPERIENCE

Include firefighting experience gained as a Paid Call, Volunteer, and or Reserve Fire Fighter and/or CDF Emergency Worker or Fire Fighter Explorer

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

COMPANY/STATE AGENCY NAME

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     




APPLICANT’S NAME (Last)

(First)

(M.I.)

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

     

     

     

     

  1. NON-FIREFIGHTING EXPERIENCE: List the applicable information specified below including classification title, location, employer, and months of experience. ALL INFORMATION WILL BE VERIFIED PRIOR TO APPOINTMENT. [MAX] 15 _________________
A.) PUBLIC SAFETY

Include work experience in a public safety area of AT LEAST 6 MONTHS DURATION (i.e., CDF Volunteers in Prevention, Military, Security Guard, Lifeguard, Dispatcher, Park Ranger)

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     
B.) MEDICAL CARE PROVIDER

Include work experience as a medical care provider of AT LEAST 6 MONTHS DURATION. Experience must include direct patient care (i.e., Ambulance Attendant, Emergency Room Technician). Do NOT include non-medical experience.

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     




APPLICANT’S NAME (Last)

(First)

(M.I.)

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

     

     

     

     

  1. NON-FIREFIGHTING EXPERIENCE, CONT.:
C.) TRADES/INDUSTRIAL/OTHER EXPERIENCE

Include trades/industrial experience of AT LEAST 6 MONTHS DURATION (i.e., Carpenter, Mechanic, Cook, etc.).

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     

FROM (MDY)

TO (MDY)

JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)

     

     

     

HOURS PER WEEK

TOTAL WORKED (Years/Months)

COMPANY/STATE AGENCY NAME

     

     

     

SALARY EARNED

ADDRESS

$      

PER      

     

DUTIES PERFORMED




     

REASON FOR LEAVING

     


NOTE: If more space is needed for experience, attach additional pages.

EQUAL EMPLOYMENT OPPORTUNITY
APPLICANT: To assist the State of California in its commitment to Equal Employment Opportunity, applicants are asked to voluntarily provide the following information. This questionnaire will be separated from the application prior to any employment decisions. Government Code Section 19705 authorizes the State Personnel Board to retain this information for research and statistical purposes.


AGE

 UNDER 21  21- 39  40-69  70 AND OVER



GENDER

 MALE  FEMALE



Ethnic Category (Please check the box that best describes your race/ethnicity):






AMERICAN INDIAN OR ALASKAN NATIVE - Persons having origins in any of the tribal peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.




ENTER TRIBAL IDENTIFICATION OR AFFILIATION:



ASIAN - Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This includes China, Japan, and Korea.



BLACK - Persons having origins in any of the black racial groups of Africa.



FILIPINO - Persons having origins in any of the original peoples of the Philippine Islands.



HISPANIC - Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.



PACIFIC ISLANDERS - Persons having origins in the Pacific Islands, such as Samoa.



WHITE - Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Check if:






OTHER (Specify)










DISABLED - A person with a disability is an individual who:

  1. Has a physical or mental impairment or medical condition that limits one or more life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working;

  2. Has a record of such an impairment or medical condition;

  3. Is regarded as having such impairment or medical condition.







MILITARY - A military veteran; a widow or widower of a veteran; or a spouse of a 100% disabled veteran.


HOW DID YOU LEARN OF THE FIRE FIGHTER I POSITION?



NEWSPAPER



RECRUITER



INTERNET - WWW.JOBS.CA.GOV



FFI HOTLINE



SCHOOL



FRIEND/RELATIVE



OTHER (Specify) ___________________________













THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
INSTRUCTIONS
Read the following instructions carefully before completing this Application. Please complete the Application on a typewriter or personal computer or print in ink. All questions must be answered completely and accurately, except as noted. You may be disqualified for any false or misleading statements or for omitting information. The information you furnish will be used to determine your eligibility and/or may be the basis for arriving at your final rating. You may be requested to provide additional information regarding your qualifications, your preference regarding work shifts, etc., and health/medical background.



Social Security Number – Please provide the last four (4) digits of your social security number.
Question 1 – Reasonable Accommodation will be provided to applicants who need assistance to participate in an interview due to a verifiable disability. If you check “yes” you will be contacted via telephone or mail to make specific arrangements.
Question 3 – The minimum age requirement for a Fire Fighter I is 18 years of age at the time of appointment. If you are not currently 18 years of age or older, please indicate your date of birth in the space provided.
Question 4 – Employment History/Discharges. These questions must be answered by all applicants. (a) You must answer “yes” if you have ever, because of poor performance or misconduct, been fired from a job, let go, or had a work contract terminated. (b) You must answer “yes” if you have ever quit a job after being informed that you were under suspicion of misconduct or poor performance or after being informed you could receive disciplinary action. (c) You must answer “yes” if you were ever advised that you would be rejected, released, or not hired permanently after a trial period. Explain any "yes" answers in Item 5. Include the facts in brief, the grounds for any action taken against you, and the circumstances under which you left the position.
SPECIAL NOTE: Verification of the items listed in Section I, Education and/or Section II, Training, may be required at the time of the interview or appointment. Acceptable verification for education is copies of your transcripts and/or diploma. The acceptable verification for training is a copy of your certificate of course completion and/or copy of both sides of your current, valid medical card.
Section I – Education. Fill in the highest level of education you have achieved and the date of completion. For college units, please indicate if semester or quarter units.
Section II – Training. Indicate all certification courses and/or emergency medical training you have successfully completed by marking “yes” or “no.”
Signature – Your signature and the date signed is required. If the Application is not signed, it may be rejected and/or may result in your missing the final filing date for this application.
Section IIIFirefighting Experience. You must include a complete list of your paid and/or volunteer firefighting work experience for the categories of: A.) CDF firefighting experience, B.) full-time non-CDF firefighting experience, and C.) paid call, volunteer, and/or reserve firefighting experience. List all firefighting jobs, regardless of duration, in the appropriate section(s) on the application.
Section IVNon-Firefighting Experience. You must include a complete list of your paid and/or volunteer non-firefighting experience for the categories of: A.) Public Safety experience, B.) Medical Care Provider experience, and/or C.) Trades/Industrial/Other experience. List all applicable information in the appropriate section(s) on the application.
State employees must list the specific departments for which they worked and indicate the specific civil service class title(s) held.
NOTE: Your completed Application and other related information submitted to CDF becomes confidential information and the property of the State of California as provided by Government Code Section 18934. This application and other confidential information will not be returned; therefore, we recommend that you keep a copy of your completed Application for your personal records.
Discrimination on the basis of race, color, creed, national origin, ancestry, sex, marital status, disability, religious our political affiliation, age, or sexual orientation is prohibited.



PLEASE ENTER YOUR NAME ON PAGES 1 THROUGH 5

AND STAPLE ALL PAGES OF THE

APPLICATION TOGETHER BEFORE SUBMITTING!


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