District Membership Application

Name (required)

Address (street number, name and any unit# with city, state and zip code) (required)

Phone Number (required)

Email Address (required)

Have you ever been employed/educated under another name? (required)

Yes

No

If yes, please state name: (required)

Position Desired (select all that apply) (required)

Date Available (required)

Desired Wage (required)

Are you a citizen of the United States? (required)

Yes

No

If no above, are you authorized to work in the United States? (required)

Yes

No

N/A

Are you 18 years of age or older? (required)

Yes

No

Have you ever been convicted of a crime other than traffic citations? (required)

Yes

No

If yes above, please explain: (required)

Have you ever had a HIPAA violation? (required)

Yes

No

If yes above, please explain: (required)

Have you ever been involved in a lawsuit? (required)

Yes

No

If yes above, please explain: (required)

Are you currently a certified provider? (If yes, select all that apply, detail other certifications held) (required)

If yes above, please upload certifications you hold.

Do you have a valid driver's license? (required)

Yes

No

Has your driver's license been suspended/revoked in the last three (3) years? (required)

Yes

No

How many driving violations in the last seven (7) years? Please describe: (required)

Please upload a copy of your driver's license. (required)

Have you ever worked/volunteered for OFPD before? (required)

Yes

No

If yes above, provide dates (from start to end) and position(s) held:

Do you have any medical conditions that would inhibit the performance of your duties? (required)

Yes

No

Current Employer Name (required)

Current Employer Address (required)

Current Employer Supervisor and Phone Number (required)

Current Employer Job Title (required)

Responsibilities (required)

Current Employer Starting Wage (required)

Current Employer Ending Wage (required)

Dates of Employment (start end and end date) (required)

May we contact this supervisor for a reference? (required)

Yes

No

Do they understand the need to be excused from work for an emergency? (required)

Yes

No

Previous Employer Name (required)

Previous Employer Address (required)

Previous Employer Supervisor and Phone Number (required)

Previous Employer Job Title (required)

Previous Employer Job Responsibilities (required)

Previous Employer Starting Wage (required)

Previous Employer Ending Wage (required)

Previous Employer Dates of Employment (start and end dates) (required)

May we contact this supervisor for a reference? (required)

Yes

No

Previous Employment #2 Name (required)

Previous Employment #2 Address (required)

Previous Employer #2 Supervisor and Phone Number (required)

Previous Employer #2 Job Title (required)

Previous Employer #2 Job Responsibilities (required)

Previous Employer #2 Starting Wage (required)

Previous Employer #2 Ending Wage (required)

Previous Employment #2 Dates of Employment (start and end dates) (required)

May we contact this supervisor for a reference? (required)

Yes

No

EDUCATION (required)

Course

Name and Address of Training Facility/School

Detail Month/Year training completed and the total classroom hours

Did you receive a certificate/diploma?

Yes

No

Obtaining Certificate/Diploma

Branch of service

Dates of active service

Describe any job-related training received in the U.S. Military

Veterans Preference (required)

Yes

No

If preference eligible, please upload copy of DD214 and SF-15

Reference #1 Name (required)

Reference #1 Relationship (required)

Reference #1 Company, address and phone number (required)

Reference #1 Email address (required)

Reference #2 Name (required)

Reference #2 Relationship (required)

Reference #2 Company, address, and phone number (required)

Reference #2 Email Address (required)

Reference #3 Name (required)

Reference #3 Relationship (required)

Reference #3 Company, address and phone number (required)

Reference #3 Email address (required)

Name (required)

Relationship (required)

Phone Number (required)

Briefly state your reasons for wanting to become a part of our organization (required)

If there is anything else that you would like to add, or detail any other items there was not sufficient room to address within this application, please detail here

Document upload - upload cover letter, resume and any other relevant documents here

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at-will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee/Member at any time with or without cause. It is further understood that this "at-will" employment relationship may not be charged by any written document of by conduct unless an authorized executive of this organization specifically acknowledges such change in writing. (required)

I agree to permit the Olathe Fire Protection District to conduct an investigation into my background through the police department, CBI, FBI, Department of Revenue, or any other law enforcement organization or background information system. This information will be held in confidence by the Olathe Fire Protection District. I have also read and understand the job description and functional position description. (required)

In the event of employment, I understand that false or misleading information stated within this application or during the interview process, may result in discharge. I also understand that I am required to abide by all rules and regulations of the Olathe Fire Protection District and this application does not grant me any right of continued employment and does not establish or create a contract of employment, either express or implied, between the Olathe Fire Protection District and myself. (required)

By signing below, I hereby attest that the above information is true and accurate, that all information provided within this application has been provided willingly, and I understand that any false or misleading information will subject me to disqualification or dismissal. (required)

By typing my full name below, I hereby attest to my identity as submitted by uploaded documents and submit this application for employment. (required)

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