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TOWN OF BUXTON
BUXTON FIRE-RESCUE DEPARTMENT

BASIC REQUIREMENTS FOR PER DIEM FIREFIGHTERS / EMT-P-I-B

·       Valid Maine driver’s license.
·       Physical examination.
·       Background and reference checks.
·       Please include a copy of your Maine State EMS License.
·       Please include any specialized training certificates.
·       Please include a copy of your current resume.
·       All applicants must provide proof of AVOC/EVOC and or CEVO training


BASIC REQUIREMENTS FOR CALL FIREFIGHTERS


·       At least 16 years of age.
·       Valid Maine driver’s license.
·       Reliable vehicle for responding to emergency calls.
·       Background and reference checks.
·       Physical examination.
·       Placed on six month probation.
·       Requested to attend department meetings and training.

clip_image03.jpgTOWN OF BUXTON
BUXTON FIRE-RESCUE DEPARTMENT  
        PER DIEM FIREFIGHTER/EMT-P-I-B               APPLICATION FORM


Full Name: ___________________________________________________________________
Address:______________________________________________________________________
Telephone:____________________          E-mail Address: ____________________________
Date of Birth:_________________  License #:________________  SSN#__________________
If you have lived outside of Maine as an adult, please provide addresses: ______________________________________________________________________________
______________________________________________________________________________
Position applying for: ____________________________________________________________

EDUCATION

High School and Graduation Date: _________________________________________________

College/University Attended and Graduation Date: ____________________________________
_____________________________________________________________________________

Other Training/Skills Relevant to Firefighter Position: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EMPLOYMENT HISTORY

Please list employers, beginning with the most recent.

Current Employer (Name, Address, Telephone): _____________________________________
Hire Date: ______________________    Position: ____________________________________
Supervisor Name: _____________________________________________________________

Previous Employer (Name, Address, Telephone): _____________________________________
Dates of Employment: _____________   Position: _____________________________________
Supervisor Name: _______________________________________________________________

Previous Employer (Name, Address, Telephone): _____________________________________
Dates of Employment: _____________   Position: _____________________________________
Supervisor Name: _______________________________________________________________

Previous Employer (Name, Address, Telephone): _____________________________________
Dates of Employment: _____________   Position: _____________________________________
Supervisor Name: _______________________________________________________________
REFERENCES

List three persons who can comment on your abilities, work habits and character whom we may contact.

Name                    Address                 Phone                           Relationship
_____________________________________________________________________________----------
_____________________________________________________________________________
_____________________________________________________________________________

BACKGROUND INFORMATION

Have you ever been disciplined, discharged or asked to resign from a prior position?
                                                                                          Yes ___ No___

Have you ever resigned from a prior position after a complaint has been received against you or your conduct was under investigation or review?                                                         Yes___  No___

Have you ever been charged with or investigated for sexual abuse of another person?                                                                                                                                       Yes___ No___

Have you ever been convicted of a crime or traffic offense?                     Yes___ No___

Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any
crime (including traffic offenses)?                                                                      Yes___No___

Has any court ever deferred, filed or dismissed proceedings without a finding of
guilty and required that you pay a fine, penalty or court costs and/or imposed a
requirement as to your behavior or conduct for a period of time in connection with
any crime?                                                                                              Yes___No___

If you answered YES to any of the previous questions, provide full details below, including with respect to court actions, the date, offense in question, and the address of the court involved (attach additional page(s) if necessary).  Conviction or other disposition is not necessarily an automatic bar to employment.

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________


Refusal to provide authorization for reference and/or criminal records checks and/or providing false or misleading information on this application shall constitute sufficient reason to refuse to employ an applicant or, if the applicant has been employed, to immediately dismiss the employee.






APPLICANT AUTHORIZATION AND ACKNOWLEDGMENT

My signature below constitutes authorization to check my employment history and, without limitation, criminal arrest and conviction record checks, driving record check, reference checks, and release of investigatory information possessed by any state, local or federal agency.  I further authorize those persons, agencies or entities that the Town of Buxton contacts in connection with my employment application to fully provide the Town of Buxton any information on the matters set forth above.  I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Town of Buxton, its agents and officials, or against any such provider of such information.


________________________________________________        Date:___________________
Applicant Signature     





Thank you for your interest in the Buxton Fire – Rescue Department.


 
Town of Buxton
  185 Portland Road, Buxton, ME 04093 (207) 929-5191
Mon, Tues, Thur, Fri 8:30am to 4:30pm & Wed: 11:30am - 7:30pm