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									         Human Resource Department
         24 N Center Street, Marshalltown, IA 50158
                     Ph (641) 754-5704
                                                                       THE CITY OF MARSHALLTOWN IS AN EQUAL OPPORTUNITY EMPLOYER

                                                                                                                                     City Use Only
Fire Chief Employment Application
This application is part of the hiring process and is used to compare each candidate using the same
information in the same format. Candidates should submit the employment application, a cover letter/letter
of interest, and resume to be considered for the Fire Chief position. Materials should be sent to the attention
of the City Human Resource Director by either email or mail. Please do not fax materials. Materials should
be received by Monday, May 31 at 12:00 P.M.

First:                                                Middle:                                     Last:

Current Address:                                                                    City:                                 State:           Zip:

Social Security #:                             Driver’s License #:                            Email:

Phone numbers: Home:                                          Cell:                                       Work:

EDUCATION AND TRAINING - Submitted resume should include a summary of education and training background including: college, high
school, technical, etc.

EMPLOYMENT RECORD - Submitted resume should include employment history. Included with employment history should be: name of
employer, dates of employment, position held & primary job duties, employer address/city/state/zip, phone number, director supervisor, and reason for

REFERENCES - Please submit a list of professional references including: name, work relationship, years known, and contact information. References
listed should be able to give an accurate account of work performance. Please do not list relatives. Applicants will be notified prior to references being

If you are currently employed, may we contact your current employer with advance notice? Yes           No

Have you ever been discharged from a job? Yes       No       If you answered yes, please explain the circumstances of the discharge(s):

Have you been convicted of a violation of the law other than minor traffic offenses? A conviction record will not necessarily eliminate you from
consideration for employment, factors such as nature and seriousness of the violation, time of offense, and rehabilitation will be taken into account.
Yes     No      If you answered yes, please explain:

If a conditional offer of employment is made, employment will be pending based upon the successful completion of both a pre-employment physical
& drug test. Do you believe that you can pass a pre-employment physical? Yes     No     Do you believe that you can pass a pre-employment drug
test? Yes     No       If you answered no, please explain:

If you can speak a language in addition to English, please list the language(s) and your degree of fluency:

                                                       The City of Marshalltown, Iowa - Page 1 of 4
How did you hear about this position opening (publication, web site, friend, city employee, etc)?

If you are not a current City of Marshalltown employee, do you know anyone who is employed by the City of Marshalltown? Yes              No       If you
answered yes, list names, departments, and how you know the employee(s) (such as relative, neighbor, friend, acquaintance, etc.):

Section 400.13 of the Iowa Code states that the chief of a fire department shall have had a minimum of five years’ experience in a fire department, or
three years experience in a fire department and two years of comparable experience or educational training. Do you meet the minimum requirement
established by the Iowa Code? Yes       No

Section 400.17 of the Iowa Code states that a person shall not be appointed or employed in any capacity in the fire or police department if the person
is addicted to narcotics or alcohol and has not been rehabilitated for a period of one year or more, or is not presently undergoing treatment; or if the
person has attempted a deception or fraud in connection with a civil service examination. Do you attest that in regard to these requirements that you
could be appointed? Yes        No      If you answered no, please do not submit an application.

Section 400.17 of the Iowa Code states that the maximum age for a police officer or fire fighter covered by this chapter and employed for police duty
or the duty of fighting fires is sixty-five years of age. Are you under 65 years of age? Yes   No

Answer the following question after you have read the Position Announcement. Do you meet all of the qualifications listed?
Yes     No      If you answered no, please explain:

All sworn fire department personnel shall live within a fifteen-minute driving time of the City limits of Marshalltown. Driving time shall mean
driving under normal conditions and within speed limits. If you are hired, do you agree to comply with this requirement within 60 days of your date
of hire? Yes     No

Are you now, or have you ever been, a certified firefighter in the State of Iowa, or for any other state? Yes    No      If you answered yes, in what
state(s) and when?

Describe your computer experience including software used and level of proficiency with each:

Describe your work ethic:

What experience do you have with budgeting?

                                                      The City of Marshalltown, Iowa - Page 2 of 4
Describe your familiarity with the International Building and Fire Code and its enforcement:

Describe your experience and training in rescue or Emergency Medical Services. Are you certified in any specific areas?

What is your experience with volunteer firefighters?

After carefully reading the class specification summary, what skills and/or knowledge (not previously discussed on this application) do you have that
would benefit the City if you were hired for this position?

Are there any incidents in your life, or details not mentioned herein, which you think might influence the City's evaluation of your suitability for
employment as Fire Chief? Yes        No       If you answered yes, please explain:

VETERANS’ PREFERENCE - Complete this section only if you are a US Military veteran and want to claim veterans’ preference points. Applicants
wishing to have points awarded for military service must submit proof of service including dates of service and type of discharge prior to or at the time of
interview. US Military Service dates: From:               To:            Do you have an honorable discharge? Yes          No      Are you a United States
citizen? Yes     No        Are you currently a resident of Iowa? Yes          No      Do you have a service-connected disability or are you receiving
compensation, disability benefits, or pension under laws administered by the veterans’ administration (an honorably discharged veteran who has been
awarded the Purple Heart for disabilities incurred in action shall be considered to have a service-connected disability)? Yes       No

                                                       The City of Marshalltown, Iowa - Page 3 of 4
AGREEMENT: Before you sign this agreement, please read the following carefully:

I have completed this application myself; no one else has completed any part of it for me.

The information provided on this application or on any information submitted with this application is true and complete to the best of my
knowledge. I agree that falsified information or significant omissions may disqualify me from further consideration for employment and may
be considered justification for dismissal if later discovered.

In order to permit the City of Marshalltown to make a thorough investigation of my background, personal habits, and character for the
purpose of determining my fitness and suitability for employment, I hereby release from liability and promise to hold harmless from any
liability under any and all possible causes of legal action, any and all persons or entities who shall furnish any information or opinions
regarding my background, personal habits, and/or character, whether or not that individual is specifically listed as a reference on this

I hereby authorize any person or entity who may be contacted by the City of Marshalltown, its agents, or employees to release to such agents
or employees any information, data, or opinions they may have regarding my background, criminal history, credit background, personal
habits, character, qualifications, and/or job performance. I understand that the source of such information or opinions provided to the City of
Marshalltown shall be confidential and that the city shall not be required to reveal the content or source of any information or opinions.

I agree to hold harmless and release from liability under any and all possible causes of legal action, the City of Marshalltown, its agents, and
its employees, for any statements, acts, or omissions in the course of its investigation into my background, personal habits, and/or character.

I understand and agree that if I am hired by the City of Marshalltown, I will have my paychecks directly deposited into a checking or savings
account(s) rather than receiving paper checks.

I realize that it may be necessary for the City of Marshalltown to thoroughly investigate my personal background and qualifications; and by
applying for employment with the city, I expressly waive all my legal rights and causes of action to the extent that the City of Marshalltown
investigation (for purposes of evaluating my suitability for employment) may violate or infringe upon these aforementioned legal rights and
causes of action of mine.

This release from liability given by me to the City of Marshalltown, its employees, or agents, and all others as heretofore provided, shall
apply to any right of action that might accrue to my self, my heirs, and/or my personal representatives.

Signature:                                                           Date:

                                                    The City of Marshalltown, Iowa - Page 4 of 4

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