Golder Ranch Fire District

Employment Application
Applicant Information
Full Name: Date:
Last First M.I.
Are you 18 years or Older? YES NO
Address:
Street Address Apartment/Unit #

City State ZIP Code

Phone: ( ) Alt Phone: ( ) E-mail Address:
YES NO YES NO
Are you a citizen of the United States? If no, are you authorized to work in the U.S.?
Desired Employment

Position Applied for: Date Available: Desired Salary: $

YES NO YES NO
Are you employed now? If so, may we contact your current employer?
YES NO
Have you ever applied to this company before? If yes, when? Where?
YES NO
Have you ever worked for this company? If yes, when? Where?

Reason for leaving?

Name of last supervisor at this company:

Who referred you to this company? Employment Agency Newspaper Advertising Friend

State Employment Office College Placement Service Walk In Other

Education
High School
or GED: Address:
YES NO Subjects
Did you graduate? Studied:

College: Address:
YES NO Subjects
From: To: Did you graduate? Studied:

Other: Address:
YES NO Subjects
From: To: Did you graduate? Studied:
General
Subjects of Special Study or Research Work

Special Training

Special Skills
 Former Employers
Provide 10 years of employment history starting with the most recent first. Attach additional pages if necessary.

Company:

Address: City State Zip

From: To: Job Title:

YES NO
Starting Salary: $ Ending Salary: $ May we contact your supervisor?

Supervisor: Title: Phone: ( )

Responsibilities:

Reason for Leaving:

Company:

Address: City State Zip

From: To: Job Title:

YES NO
Starting Salary: $ Ending Salary: $ May we contact your supervisor?

Supervisor: Title: Phone: ( )

Responsibilities:

Reason for Leaving:

Company:

Address: City State Zip

From: To: Job Title:

YES NO
Starting Salary: $ Ending Salary: $ May we contact your supervisor?

Supervisor: Title: Phone: ( )

Responsibilities:

Reason for Leaving:

Company:

Address: City State Zip

From: To: Job Title:

YES NO
Starting Salary: $ Ending Salary: $ May we contact your supervisor?

Supervisor: Title: Phone: ( )

Responsibilities:

Reason for Leaving:

 References
Below, give the names of three professional references, whom you have known at least one year. Do not list relatives.

Full Name: Years Acquainted

Company: Phone: ( )

Address:

Full Name: Years Acquainted

Company: Phone: ( )

Address:

Full Name: Years Acquainted:

Company: Phone: ( )

Address:

Service Record

Branch of Service: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:

Criminal Background
YES NO
Have you ever been convicted of any misdemeanors?
If yes, please provide
date(s) and explain:

YES NO
Have you ever been convicted of a felony?
If yes, please provide
date(s) and explain:

YES NO
Are there any criminal charges currently pending against you?
If yes, state the nature
of the charges and
current status. This
does not include civil
traffic cases.
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
I also understand that Golder Ranch Fire District, being an at-will employer, may terminate my employment at any
time, with or without cause and without liability, and that my employment does not constitute a contract of employment
between myself and the District. I will comply with and be governed by all federal and/or state laws, and District
policies, rules, and procedures as may be in effect.

Signature: Date: