Franklin County Fire Department 106 Darby Shire Circle Frankfort, Kentucky 40601 Phone: (502) 695-1617 Phone: (502) 695-9934 Fax: (502) 695-4457

Personal Information:

Name (Last, First)
Present Address:	City:	State:	Zip:
Permanent Address:	City:	State:	Zip:
Phone Number (  )	Date of Birth	Email Address:

Employment Desired:

Position:	Date you can start:	Salary Desired:
Are you employed now?  Yes No	If so, may we inquire of your present employer?  Yes No	Are you legally Authorized to work in the US?  Yes No
Do you have a valid driver's license if required by the position for which you are applying?  Yes   No		Drivers License Number:
Has your drivers license ever been revoked or suspended?  If yes, please indicate period of suspension and reason.
Have you ever been convicted of violating any law (omit minor traffic violations)?  If yes, list convictions(s), date(s), and place(s),  Conviction is not an automatic rejection.  All applicants shall have a criminal records/background check.

Education History:

	Name & Location of school	Years Attended	Did you graduate?	Subjects Studied
High School			Yes     No
College			Yes     No
Trade, Business, or, Correspondence School			Yes     No

General Information:

Subjects of Special Study/ResearchWork:
Special Training:
Special Skills:
US Military:    Yes     No	Branch and Rank:

Former Employers (List below last four emplayers with last one first)

	Date Month and Year	Name Address of employer	Salary	Position	Reasons for Leaving
From
To
From
To
From
To
From
To

References give blow the names of three persons not related to you, whom you have known at least one year.

Name	Address	Phone	Years known

Signature - Please read and sign the following statement: I certify, under penalty of law, that the information given in this application is correct and complete to the best of my knowledge. I am aware that, should investigation at any time show falsification, I will not be considered for employment or, if employed, I will be dismissed and disqualified from future merit examinations.  I hereby authorize all necessary investigations concerning me, my academic records or other material pertinent to my qualifications.  I authorize and request each former employer given as a reference, educational institution, or organization (including law enforcement agencies) to provide all information that may be sought in connection with this application. 

Date

Signature

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