MOORESVILLE FIRE DEPARTMENT

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					Mooresville Fire Department                                              Part Time Employment Application


                                  MOORESVILLE FIRE DEPARTMENT
                                  Part Time Firefighter / EMT Application

EXPLANATION OF HIRING PROCESS - Reserve & Reserve Stand-By Firefighters

1. Applications must be completed in their entirety and all documents required for submittal with the
   application must be included. Failure to follow any of the guidelines will result in immediate
   disqualification from consideration.

2. Applications and required documents must be returned to the Mooresville Fire
   Department. Applications may be returned by mail. Completed applications should be
   sent to 26 South Indiana Street, Mooresville, IN 46158.

3. The Mooresville Fire Department reserves the right to reject any and/or all applications.

4. Oral interviews will be conducted by an Interview Board. All applicants will be contacted
   with the time and date for this interview.

5. Determination of an offer for employment will be based upon the following: Review of applicant
   information, information including all submitted documents, a background investigation, qualifications,
   certifications, past employment history, results of the department interview and respirator clearance
   physical.

6. Applicants offered employment with the Mooresville Fire Department must complete a basic training
   program before being accepted as a firefighter.
Mooresville Fire Department                                              Part Time Employment Application


POSITION REQUIREMENTS

1.    The applicant must be at least 18 years of age.

2.    The applicant must have a high school diploma or its equivalent (GED) and include a copy
      of such with the employment packet.

3.    The applicant must have a valid driver's license and include a copy such with the
      employment packet. All applicants must provide a copy of their driving
      record not more than 30 days old.

4.    The applicant must provide a current copy of their criminal history.

5.    The applicant must be a citizen of the United States.

6.    The applicant must assist and cooperate with the Mooresville Fire Department in obtaining
      any additional records such as, past employment records, medical records, criminal records
      and/or personal history which may be requested during this process. Failure to cooperate
      may be considered cause for disqualification. If it is found that any requested information
      has been falsified, the applicant will be eliminated from further consideration. If the
      applicant is employed by the time the falsification is discovered the Mooresville Fire
      Department has grounds for immediate termination of the applicant.

7.    The applicant must possess physical, emotional, and mental attributes compatible with the
      essential functions of firefighting. Applicants, prior to appointment, must successfully
      pass a physical examination with a certified physician of their choice at their expense.

8.    The applicant cannot be appointed, reappointed, or reinstated, if there exists a felony conviction on
      his/her record. (See Policy Statement Re: Ex-Offenders)

9.   The applicant must be able to read and write legibly, as well as speak, hear, understand, and otherwise
     communicate in the English language. These abilities are essential job functions, and are not amenable
     to accommodations.

10. If appointed to the Mooresville Fire Department, the individual must establish residency within the
    State of Indiana for Standby/Reserve Firefighters and within the Buffer Zone as established by the
    Town of Mooresville for Reserve Firefighters. Residency within these limits must be maintained
    throughout employment, unless a change in the current residency policy is made at a later date. Failure
    to do so will result in termination of employment.

11. The applicant must successfully complete a basic training program before being accept as a
    regular probationary firefighter.
Mooresville Fire Department                                             Part Time Employment Application


POSITION DESCRIPTION

This a brief description of the position being offered. This description may be change or added to at
anytime during employment. This includes but is not limited to the following:

ORIENTATION AND TRAINING:
The orientation and training consists of up to 50 hours of mandatory training set by the Board of Fire
Fighting Personnel Standards and Education. The exact amount of this training will be based on the
certification level of the new employee. This will take place prior to the employee being released to
respond to the scene of an incident.

CERTIFICATION REQUIREMENTS:
All Reserve firefighters must obtain and maintain a minimum of the following throughout their
employment with the Mooresville Fire Department:

1.   State of Indiana Second-Class or Firefighter I Certification. (1st Year)
2.   State of Indiana Emergency Medical First Responder Certification. (1st Year)
3.   State of Indiana driver's license
4.   Residency in the Town of Mooresville or within 2 miles of the corporate limits

All Reserve/Standby firefighters must maintain a minimum of the following throughout their employment
with the Mooresville Fire Department:

1.   State of Indiana Second-Class or Firefighter I Certification.
2.   State of Indiana Emergency Medical Technician Certification.
3.   State of Indiana Driver's License.
4.   Residency in the State of Indiana
Mooresville Fire Department                                                Part Time Employment Application


BASIC LIST OF DUTIES AND RESPONSIBILITIES FOR A PROBATIONARY FIREFIGHTER

DUTIES AND RESPONSIBILITIES include the following. Changing circumstances may result in the
addition, deletion, or modification of duties and responsibilities.

1. Perform all fire, rescue, and medical related duties of the Mooresville Fire
   Department in emergency and non-emergency conditions.

2.   Conduct himself/herself in a proper and professional manner at all times so as to
     protect the life and property of the people of Mooresville.

3.   Directly report to their assigned officer at all times, and follow instruction given by
     those officers.

4. Perform all assigned duties in the absence of their assigned officer.

5.   Stay familiar with the Mooresville Fire Department operating manual, policies and
     procedures, dress code and protocols and abide by the contents of these at all
     times.

6.   Respond to all incident responses when available and as outlined in the
     performance requirements for the Mooresville Fire Department..

7.   Maintain residency in the area outlined for the position being requested.

8.   Maintain the knowledge, skills, and abilities to perform all aspects of normal
     modern firefighting operations.
Mooresville Fire Department                                               Part Time Employment Application


POLICY STATEMENT ON THE EMPLOYMENT OF EX-OFFENDERS

Consideration for employment of Ex-Offenders will be given without regard to race, creed, color, national
origin, sex, or age. The term Ex-Offenders as used herein, refers to anyone convicted of any criminal
statute or a military offense while in the service.

FELONY CONVICTIONS
In accordance with Indiana State Law , a person may not be appointed, reappointed, or reinstated if there is
a felony conviction on his/her record.

EVALUATION
With respect to all other criminal convictions which are not felonies, in each case the Mooresville Fire
Department will consider whether the prior criminal conviction or military offense conviction of the
applicant will have a bearing on the applicant's job performance or tend to measure job capability. The date
and nature of the offense, the requirements of the position for which considered, as well as, the applicant's
other qualifications will be considered.

As a matter of policy, every effort will be made to keep the applicant/employee's criminal record
confidential. During the selection process, it will be necessary to inform specific individuals directly
involved in the process of the applicant's record.
Mooresville Fire Department                                               Part Time Employment Application


APPLICATION FOR EMPLOYMENT

Information in this application will be used in background checks; the information is required for public
safety positions. The information contained in this form will be kept confidential. It is essential that all
information be completed throughly and accurately. Use additional paper if necessary for complete
information.
Fill out the application completely with the information requested. (Print or type)

Position Being Applied for :       ____Reserve            ____Reserve Stand-By

PERSONAL INFORMATION

Name: ______________________________________________________________________________
                Last                 First           middle             Maiden

Address: _____________________________________________________________________________
                           Street                              City

          _____________________________________________________________________________
                            State                         Zip Code

Phone: (____) _________________ (____) _____________________ (____) _____________________
                   Home                       Work                        Other

E-Mail Address _______________________________________________________________________

Date of Birth________________Social Security Number ______________________________________

Have you ever applied to this department before?                  YES         NO

If yes, when? _________________________________________________________________________

AFFILIATION
Have you ever been affiliated with another fire department? YES NO
If yes, Name of Department
Address___________________________________________________Phone (___) _________________

Dates of Affiliation ___________________________________________ Position___________________
Mooresville Fire Department                                           Part Time Employment Application


DRIVING INFORMATION

Do you have a valid driver's license? Yes    No      State_______Exp.Date______________

Type of License:(Operator's, etc.)_________________License Number____________________

License Restrictions______________________________________________________________

List the types of vehicles you have operated.__________________________________________
List any vehicle accidents in which you were involved during the past five (5)years:
Date             Location               Description
_________       ________________         ____________________________________________

_________      ________________         ____________________________________________

_________      ________________         ____________________________________________

List any moving traffic violation citations you have received during the past five (5) years:
Date           Location                 Description                         Type of citation
_________     _______________           ___________________________         _______________

_________     _______________        ___________________________          _______________

_________     _______________        ___________________________          _______________


Has your driver's license ever been suspended or revoked? Yes No If yes, state reason (s):
______________________________________________________________________________________
______________________________________________________________________________________


CRIMINAL HISTORY

Have you ever been arrested and/or had any criminal convictions?              Yes        No

If Yes, explain circumstance(s):____________________________________________________
Mooresville Fire Department                                         Part Time Employment Application


EDUCATION

Provide the following information about your educational background and achievements.
Use additional paper if more room is needed to list the information required.

TYPE OF               NAME AND LOCATION                  ATTENDED      TYPE OF
EDUCATION             OF SCHOOL / INSTITUTION            FROM - TO     DIPLOMA
                      DEGREE/CERT.

High School         ______________________           __________         _____________
                    ______________________           __________         _____________
                    ______________________           __________         _____________

College /           ______________________           __________         _____________
Trade School        ______________________           __________         _____________
                    ______________________           __________         _____________


Fire Service        ______________________           __________         _____________
                    ______________________           __________         _____________
                    ______________________           __________         _____________


EMS Education       ______________________           __________         _____________
                    ______________________           __________         _____________
                    ______________________           __________         _____________


Other              ______________________            __________         _____________
                   ______________________            __________         _____________
                   ______________________            __________         _____________

MILITARY

Have you ever been in the military service?   Yes   No   If Yes, from_________to_________

Branch of Service __________________________________ Type of discharge ____________


CITIZENSHIP

Are you a U.S. Citizen? Yes________________No___________________
Mooresville Fire Department                                             Part Time Employment Application


RESIDENCY INFORMATION

List below all places in which you have lived within the past ten (10) years, beginning with your current
address:

       Addresses (including city & state)                            Dates of residence
_____________________________________________                   _______________________
_____________________________________________                   _______________________

_____________________________________________                   _______________________
_____________________________________________                   _______________________

_____________________________________________                   _______________________
_____________________________________________                   _______________________


EMPLOYMENT EXPERIENCE

List below all employers, starting with the current employer.

COMPANY______________________________________    FROM-TO________________
ADDRESS___________________________________________________________________
REASON FOR LEAVING_____________________________PHONE (      )_____________

COMPANY______________________________________    FROM-TO________________
ADDRESS___________________________________________________________________
REASON FOR LEAVING_____________________________PHONE (      )_____________

COMPANY______________________________________    FROM-TO________________
ADDRESS___________________________________________________________________
REASON FOR LEAVING_____________________________PHONE (      )_____________

COMPANY______________________________________    FROM-TO________________
ADDRESS___________________________________________________________________
REASON FOR LEAVING_____________________________PHONE (      )_____________

REFERENCES

Provide the names of three (3) people NOT related to you, which that have known you at least five (5)
years.

Name              Address                      Phone            Years Known
________________ _____________________________ (____)___________ __________

________________ _____________________________ (____)___________ __________

________________ _____________________________ (____)___________ __________

I, the undersigned, certify that the information contained on this document to be true to the best of my
knowledge. I understand that efforts will be made to verify the information. I further understand that
falsification of information may result in elimination from further consideration for employment. If
falsification herein is discovered after employment with the Mooresville Fire Department, it may result in
termination of that employment.

________________________________________                            ________________________
       APPLICANT'S SIGNATURE                                                  DATE
Mooresville Fire Department                                              Part Time Employment Application


AGREEMENT


I, _______________________an applicant for the position of Probationary Firefighter with the Mooresville
Fire Department agree to assist and cooperate with this Department and any representative thereof in
obtaining the following personal history information:

Criminal History Records                                         Driving Records
Medical Records                                                  Educational Records
Employment History                                               Credit Record

and hereby authorize and request all persons to whom this agreement (copy or original) is presented, having
information relating to or concerning me, to furnish any duly appointed officer or individual of the
Mooresville Fire Department with such. I hereby release Mooresville Fire Department, my prior employers,
schools, or other persons from any and all liability for any damage that may result from their furnishing
information concerning me.

I understand that the employment process includes psychological, physical, and medical tests, including but
not limited to blood tests, urinalysis, and/or breathalyser, and that the tests are meant in part to determine
whether I have recently consumed and/or am under the influence of alcohol, intoxicants, or non-prescribed
drugs, as well as my general fitness for employment. I understand that my failure to submit to such tests
will result in immediate disqualification from any further consideration for employment, and that the results
of the tests may be disclosed to any duly appointed officer or individual of the Mooresville Fire
Department, it's government officials, and legal counsel in the process of an employment decision.

I understand that misrepresentation or falsification of information on this or any other documents included
in the application process, or failure to assist and cooperate with this Department in obtaining the above
requested information will be cause for disqualification from consideration for employment and I authorize
investigation of all statements contained on this and any other of the documents included in the application
process.

I understand I must provide the Department with photocopies of the following:
         Valid Driver's License
         Driving Record
         Criminal History
Proof of high School Diploma or equivalent
Official Birth Certificate
EMS/Fire Certifications as appropriate
Discharge (DD-214) Form from Military Service (if applicable)
Mooresville Fire Department                                              Part Time Employment Application


    If I am chosen for employment with Mooresville Fire Department, I understand that,
throughout my employment, the Department has the right to request psychological, physical, and medical
examinations, and tests (such as previously described), investigate my personal, employment, financial,
medical history, and all other related matters, as well as verify my on going suitability and fitness to serve
as a public safety officer. I here by authorize such investigations, agree to cooperate, and understand that
the results of such tests and investigations may be disclosed to any duly appointed officer or individual of
the Mooresville Fire Department, it's government officials, and legal counsel. I further understand that the
results of such tests and investigations may result in corrective action, up to and including discharge, and
that refusal to cooperate are grounds for recommendation for immediate termination. I further understand
that misrepresentation or falsification of this or any other of the documents in the application process, even
if not discovered until after my employment, are grounds for termination. However, I also understand that
under no circumstances will I be required to waive my immunity, and results of medical examinations
(including drug tests) shall not be used without my consent in any subsequent court proceeding.

If employed by the Mooresville Fire Department, I agree to abide by all rules and regulations of the
Mooresville Fire Department and understand that employment policies or manuals issued by the
Mooresville Fire Department may be modified, amended, or terminated by the Department from time to
time.

Date this___________day of__________________,20____


                                     __________________________________________
                                                     Applicant's Signature

Subscribed and sworn before me this day of___________________, 20____

                                           Notary Public_____________________

                                           My Commission Expires____________

                                           County of Residence_______________

______________________________
         Notary Seal
Mooresville Fire Department                                             Part Time Employment Application


APPLICATION COMPLETION INSTRUCTIONS

All forms included in this application packet MUST be completed EXACTLY as instructed below and
returned to the Mooresville Fire Department, Administrative Office, 26 South Indiana Street Mooresville,
IN 46158 Also, participation in the Selection Process will be denied to individuals presenting incomplete
application packets.
IF YOU ARE MISSING ANY PART LISTED BELOW, HAVE ANY QUESTIONS, OR EXPERIENCE
DIFFICULTY OBTAINING OR COMPLETING ANY PART OF THE APPLICATION, CONTACT THE
OFFICE FOR GUIDANCE AND ASSISTANCE PRIOR TO THE DEADLINE!!

USE THE FOLLOWING AS A CHECKLIST:
I. APPLICATION FORM
A: Type or print the information requested.
B: Leave no blanks -- write "none" or "not applicable (N/A) where necessary."
C. Agreement
    1. Notarized applicants' signature.
       a. Applicant must sign this in the presence of a Notary Public.
       b. Application will NOT be accepted if not notarized.

D: Photostat copies of the following MUST accompany the application when submitted:
   1. Birth Certificate
   2. Driving Record
   3. Valid Driver's License
   4. Criminal History
   5. High School Diploma or equivalent
   6. Form DD-214 if formerly in Armed Service
   7. EMT Certification
   8. Second Class Firefighter or Firefighter I Certification

II. BACKGROUND INFORMATION
A. Type or print the information listed
B. Be as complete and as accurate as possible
C. Sign and date the last page of the background information section.

III. PERFORMANCE TEST WAIVERS (If Applicable)

A. Thoroughly read and understand all of the information presented in this form. Any questions you have
    will be answered as well as possible.
B. The Performance Task Test - Informed Consent Waiver must be signed in the presence of a notary.
   Notarization of this form is required.
C. Application will NOT be accepted if these forms are not signed and/or included in an application
   packet.


SPECIAL NOTE: It is preferable that your application be returned in person. You may mail your
application if you chose, but the Department cannot grant extensions or exceptions for applications lost or
delayed in the mail, nor will the Department be responsible for delay or loss of the testing information in
the mail. Failure to return all forms precisely as described above by the deadline, results in elimination
from employment consideration.

				
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