Date:  

Email:

SAVANNA FIRE DEPARTMENT APPLICATION FOR EMPLOYMENT
PAID ON CALL

Applicant Name (FIRST MIDDLE LAST):     

Marital Status:    Married Single Divorced Widowed       Date of Birth:   

Phone Number:      

Social Security #:   

Home Address Street:   

Home Address City:       

State:      Zip Code:   

Length of Residency in Savanna:  

Drivers License

Number:        Expires:     

Classification:        Restrictions:   

Education:

Elementary School:   

Junior High School:   

High School:   

College:   

Trade School:   

Relative that can be notified in case of an emergency:   

Name:    Phone:

Name of Spouse (FIRST MIDDLE LAST):   

Physical Information :

Neck:    Chest:     Waist:    
Inseam:    Shoes:    

Please describe physical defects, if any:

Do you have a hernia?   Yes     No    

Are you taking any medication(s)?   Yes     No  

Do you have a felony record?   Yes     No

List skills such as First Aid, CPR, Etc:   

Shift Availability:    6AM to 6PM      6PM to 6AM

How would you help our Fire Department?

Name and Addresses of Two References:
Reference 1 Name Address City, State Zip Phone Number     
Reference 2 Name Address City, State Zip Phone Number

Your Current Place of Employment:   

Signature:    ______________________________________________

SAVANNA FIRE DEPARTMENT AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I,___________________________, do hereby authorize the release, and/or review of full disclosure of all records concerning myself to the Savanna Fire Department, whether the said records are of a public, private or confidential nature. The intent of this authorization to give my consent for full and complete disclosure of records of educational institutions; financial or credit agencies (including credit reports, and/or ratings); and other financial statements and records; employment and pre-employment records, including background reports, and performing ratings, but excluding information relating to medical conditions and medical history (unless a conditional offer of employment has been made); and, all records maintained by any criminal justice or corrections agency including, but not limited to, incident reports, arrest records and criminal history information. I understand that any information obtained by a personal history background investigation, which is developed directly, or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the City of Savanna. I also agree to hold harmless any person(s) who may furnish such information concerning me; and I hereby release said person(s) from liability which may be incurred as a result of furnishing such information. A photocopy of this release form will be valid as an original thereof, even though said photocopy does not contain an original writing of my signature. I have read and full understand the contents of this "Authorization for Release of Personal Information". I understand that all information and documents turned over to the Savanna Fire Department become the property of the Savanna Fire Department and will not be returned to me.

SIGNATURE:_______________________________________________

ADDRESS:_________________________________________________

PHONE NUMBER:____________________________________________

DATE OF BIRTH:____________________________________________

SOCIAL SECURITY NO.:______________________________________

WITNESS:_________________________________________________

DATE:____________________________________________________