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TRAVIS COUNTY EMERGENCY SERVICES DISTRICT

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					       TRAVIS COUNTY
EMERGENCY SERVICES DISTRICT #4




         APPLICATION
          11800 North Lamar #4B
           Austin, Texas 78753
              (512) 836-7566
AUTOMATIC DISQUALIFIERS

Read all of the automatic disqualifiers before completing your application.
Important: If you are not sure if any of the automatic disqualifiers pertain to you, you are
required to submit a detailed letter explaining the circumstances in question.

Application Disqualifiers
Any of the following will disqualify the applicant from further consideration during any phase of
the process.
       1. Failure to submit an application by the required notified deadline date.
       2. Failure to submit all required documentation or information by the required notified
           deadline date.

Criminal Disqualifiers
Any of the following will disqualify the applicant from further consideration during any phase of
the process.
       1. Having a conviction for, or being under indictment for, or currently charged with any
           felony offense.
       2. Having any conviction for any Class A or Class B misdemeanor offense, or currently
           being under indictment for, or currently charged with any Class A or Class B
           misdemeanor offenses (within the past 5 years).
       3. Having a conviction for driving under the influence (DWI/DUI) within the past 5
           years or being under indictment for, or currently charged with driving under the
           influence (DWI/DUI).
       4. Currently serving community supervision/probation for any offense.

For the purposes of the above requirements, a person is considered convicted of an offense when
an ADJUDICATION OF GUILT is entered against said person by a court of competent
jurisdiction, or a PLEA OF GUILTY is entered, including situations where:
        1. The sentence is subsequently probated and the person is discharged from probation.
        2. Deferred adjudication is granted.

Having excessive records of traffic convictions or negligent traffic collisions.
      This is defined as:
      1. Involvement as a driver in three or more motor vehicle accidents (within the past 3
          years) where the applicant’s actions contributed to the accident in any way, whether
          or not citations were issued.
      2. Convictions for more than two moving violations within the past 3 years.
      3. A driver’s license suspension within the past 3 years for:
              • DWI/DUI
              • Failure to carry liability insurance
              • For any reason that would indicate poor driving behavior




TCESD#4-Application-5/2011
                                                                                                 1
Military Disqualifiers
Having been discharged from military service with a DISHONORABLE discharge or a
GENERAL discharge indicating:
       1. Bad conduct
       2. Any other characterization indicating bad character

Drug Use Disqualifiers
      1. Illegal use of Marijuana, any controlled substance or illegal drug, within the past 3
         years.
      2. Having a police record of illegal drug usage or having illegally furnished any illegal
         or dangerous drug to another.


General Disqualifiers

          1. Being a member of any organization that advocates the overthrow of a governmental
             agency by force of violence.
          2. Currently, have belonged to, or been closely associated with any organization which
             advocates or engages in unlawful conduct directed at individuals or groups based
             upon the individual’s or group’s race, sex, religion, national origin, age, sexual
             preference, disability, or conduct otherwise commonly known as “Hate Crimes”.
          3. Making any false statement of fact, being deceptive by statement or omission in this
             application, or by any means in any part of the hiring process will result in
             disqualification and may be grounds for future dismissal.




TCESD#4-Application-5/2011
                                                                                                    2
Please carefully read all of the material in the enclosed Application.

All documents requested must be obtained and returned with the completed application. Each
line item or question must be addressed, “N/A” (not applicable) if necessary. Unanswered items
or questions will be considered incomplete and the application will not be processed. Instructions
for obtaining requested documentation is enclosed, as well as an overview of the application
process.

     1.   Complete application by either:
             • Printing out to complete, or
             • Complete online and printout.
          Submit application with the requested documents to the District Office. (Application
          cannot be submitted online).

     2.   After the application is returned to the District Office, the criminal history and driving
          record will be reviewed by the Travis County ESD #4 Commissioners at their monthly
          meeting. Commissioners at this point can approve, deny, or make provisional
          recommendations to the Fire Chief.

     3. All approved academy applicants will be required to go through a medical/physical exam
        and drug test.


                  ALL APPLICANTS MUST SUPPLY THE FOLLOWING DOCUMENTS


      Completed and signed application                  Copy of High School and College transcripts
      Original DPS criminal history                     Copy of current automobile insurance
      Copy of Valid Driver’s License                    Copy of original DPS driving record-Type 3
      Copy of Immunization records                      Copy Social Security card
      Copy of high school diploma or GED                Copy of Military DD214, if applicable
      Copy of COG Badge, if applicable
          (Clinical Operating Guidelines)




TCESD#4-Application-5/2011                                                                        3
Position applying for:  Paid FF/EMT  Cadet Academy
PERSONAL INFORMATION


Date:
Name:

Last                                            First                              Middle
Address:                                                                           Apt #:

City:                                  State:                                      Zip:


Social Security :

Date of Birth:

Driver’s License Number :                                            State:                Class:

Home Phone Number:                                           Cell Number:

Email Address:

EDUCATION

                                                                                              If you have not
 High School         Name and location of High School Last           Did you Graduate?       graduated, check
                                                                                          highest level completed
                     Attended
                                                                      Yes  No     9 10 11 12
                                                                                       
                     If you have not graduated from High School, have you passed the GED Test?
     GED
                       Yes     No             Place:
                              Name and Location of School                  Courses          Certification
 Business                                                                Completed          Received

 Technical

 Vocational

     Colleges or Universities            Location       Hours completed   Graduated       Degree Received
                                                            to date
                                                                          Yes   No
                                                                               

                                                                          Yes No
                                                                           




TCESD#4-Application-5/2011                                                                                     4
MILITARY SERVICE

Military Service :            Yes    No      Branch of Service:
Date of Enlistment:                            Year of Discharge:
Type of Discharge:                             Grade/Rank:

EMPLOYMENT EXPERIENCE
Start with your present job. Include any job-related military service assignments and volunteer
activities.

Employer:

Phone Number:

Job Title:                                        Supervisor’s Name:

Starting Date:                                    End Date:
Reason for Leaving:



Employer:

Phone Number:

Job Title:                                        Supervisor’s Name:

Starting Date:                                    End Date:
Reason for Leaving:



Employer:

Phone Number:

Job Title:                                        Supervisor’s Name:

Starting Date:                                    End Date:
Reason for Leaving:




TCESD#4-Application-5/2011
                                                                                                  5
PREVIOUS FIREFIGHTER/EMT TRAINING

Firefighter (if applicable)                     EMT Training (if applicable)
     Paid  Volunteer                             Basic  Intermediate  Paramedic
Name of Department:

                                                TDSHS #:                 Expires:
TCFP Certified                Yes    No       NREMT#:                  Expires:

Years of Service:

Level of Training:
Reason for leaving:



REFERENCES
List three references (if applicable, use only one from Travis County ESD#4)

Name:                                                  Phone Number:

Address:

City:                                 State:                     Zip:

Years known:                                    Relationship:


Name:                                                  Phone Number:

Address:

City:                                 State:                     Zip:

Years known:                                    Relationship:


Name:                                                  Phone Number:

Address:

City:                                 State:                     Zip:

Years known:                                    Relationship:


EMERGENCY CONTACT
Name:                                                      Phone #:
Name:                                                      Phone #:
TCESD#4-Application-5/2011                                                             6
ACKNOWLEDGEMENT

Please read carefully, initial each paragraph and sign below.

I understand that this application and any attachment(s) are the property of Travis County
ESD #4 and will become part of my personnel file. _______ (Initial here)

I hereby certify that the information in this application is true and correct to the best of my
knowledge. I further certify that I, the undersigned applicant, have personally completed this
application. I understand that any misrepresentation, falsification or omission of information
from this application shall be grounds for rejection of this application or immediate discharge
regardless of the time elapsed before discovery. ________ (Initial here)

I hereby authorize Travis County ESD #4 and its agents to thoroughly investigate the
information on my application, my references, work record and education. In addition, I hereby
release Travis County Emergency Services District #4, my former employers and all other
persons or entities from any and all claims, demands, or liabilities arising out of or in any way
related to such investigation or disclosure. _______ (Initial here)

I agree to abide by the Travis County ESD #4 policies, rules and regulations. I understand and
agree that Travis County ESD #4 is an ‘at will’ employer and my services may be terminated at
any time. ________ (Initial here)




______________________________________                ____________________________________
Applicant’s Signature                                  Date


___________________________________________________
Printed Name




TCESD#4-Application-5/2011
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