Volunteer Firefighters for Ayton, Durham, and Neustadt Stations

WEST GREY FIRE SERVICE Fire Chief Phil Schwartz 179 George Street West, Box 664 Durham, ON N0G 1R0 E-mail: pschwartz@westgrey.com Adm. (519) 369-2505 Fax: (519) 369-2121 Application for Employment Please Print Name: Last ______________________1st _____________ Middle _____________ Physical Address: ____________________________________________________ Phone: Home:_________________ Cell:________________ Work:_____________ Drivers Licence #: ________________________ Class: ___________ Are you legally eligible to work in Canada: Yes ___ No ___ Have you ever been convicted of a criminal offence for which a pardon has not been granted: Yes ____ No ____. If yes give Details: Are you over 18 years of age and less the 60 years of age: Yes _______ No ______ Are you willing to do on call and or shift work as may be required by the position? Yes _____ No ______ Have you applied here before? Yes _____ No _____ if yes, when? _______________________________ Education: Circle the highest grade successfully completed: Grade; 9 10 11 12 College; 1 2 3 4 University; 1 2 3 4 List any Technical or Vocational, Certificates; _____________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Special Skills: Currant First Aid CPR Certificate; Yes ____ No ____ If Yes with whom; _________________ De-fib Training; Yes No Other Skills: _____________________________________________________________________________________ _____________________________________________________________________________________ Employment History: List all previous employers, attach additional pages as required, not required to reveal wages Your present or last job: Employer:____________________________________________________________________________ Address:__________________________________ Job Title:__________________________________ Phone number; ______________________________ Employed From: __________________ To: _________________________ Supervisor: _______________________________His /Her Title: ______________________________ Reason for leaving; ___________________________________________________________________ Brief description of your position: _______________________________________________________ 2nd Last Job: Employer:____________________________________________________________________________ Address:__________________________________ Job Title:__________________________________ Phone number; ______________________________ Employed From: __________________ To: _________________________ Supervisor: _______________________________His /Her Title: ______________________________ Reason for leaving; ___________________________________________________________________ Brief description of your position: ___________________________________________________ 3rd Last Job Employer:____________________________________________________________________________ Address:__________________________________ Job Title:__________________________________ Phone number; ______________________________ Employed From: __________________ To: _________________________ Supervisor: _______________________________His /Her Title: ______________________________ Reason for leaving; ___________________________________________________________________ Brief description of your position: _______________________________________________________ ___________________________________________________________________________________ 4th Last Job Employer:____________________________________________________________________________ Address:__________________________________ Job Title:__________________________________ Phone number; ______________________________ Employed From: __________________ To: _________________________ Supervisor: _______________________________His /Her Title: ______________________________ Reason for leaving; ___________________________________________________________________ Brief description of your position: _______________________________________________________ ___________________________________________________________________________________ APPLICANT PLEASE READ CARFULLY BEFORE SIGNING: The information I have given is true and correct; I also give consent to the West Grey Fire Service to collect any personal information about me that may assist with the hiring process. This includes but not limited to Police Criminal back ground checks, educational background, former and present employers through references listed on this application form and drivers abstract. And further more; I understand that any false statement will result in termination of the hiring process. And furthermore; I agree and understand that any false misrepresentation of the facts shall constitute just cause for the termination of my employment/ or association of the West Grey Fire Service, at any time. DATED: __________________________ Signed: ___________________________________________