DEPARTMENT

Employment Application for:
Greenfield Township Fire Department
3245 Havensport Road
Carroll, Ohio 43112-9448
Business: (740) 756-4644
Fax: (740) 756-7880
Instructions
The personal history questionnaire is intended for the use of the Greenfield Township Fire
Department, personnel administration section. You must be truthful and complete all answers
requested on this form. All information contained herein is subject to verification, i.e. source
documentation. Information contained herein will be considered confidential and will not be disclosed
to any unauthorized person(s).
GREENFIELD TOWNSHIP
FIRE DEPARTMENT
The answers to questions contained in the questionnaire must be legible (handwritten in black ink
and/or typewritten). Each individual question must be answered, there can be no blanks. If a question
does not apply to your particular circumstance, insert: DNA in that blank (Does Not Apply). When
answering questions, you must provide complete information when requested. Partial responses are
not acceptable.
PLEASE ATTACH COPIES OF ALL TRAINING/CERTIFICATES, DRIVER’S LICENSE, BIRTH
CERTIFICATE, DIPLOMA(S), SOCIAL SECURITY CARD, CERTIFICATION CARDS, ETC, THAT
PERTAINS TO THE JOB REQUIREMENTS OF GREENFIELD TOWNSHIP FIRE DEPARTMENT. IF
COPIES ARE NOT ATTACHED, APPLICATION WILL NOT BE LOOKED AT.
WARNING:
Applicants are cautioned to answer every question truthfully and without evasion. Both the Ohio
Revised Code and Rules and Regulations of the Greenfield Township Fire Department, provide
penalties for making a false statement of material fact, or for practicing any fraud or deception in
obtaining or attempting to obtain municipal employment. Such penalties include rejection of
appointment or discharge after appointment and/or prosecution under the Ohio Revised Code.
Personal History of:_______________________________________________________
(Last Name)
(First Name)
(M.I.)
Position Applied For: (check one)
Full Time _____ Part Time ____ Volunteer ____
Note: All applicants are hired in a Volunteer position to start, if you check that you would like
Full Time or Part Time, then once you have successfully completed all tasks of a Volunteer
and when PT, or FT positions become available, you may then be considered for that position
if you have the required qualifications.
I hereby certify that the following answers are complete and true to the best of my knowledge and
belief. I understand that falsification of this record will be a cause for disapproval of my appointment
and/or discharge after appointment, and may subject me to prosecution under the Ohio Revised
Code.
Signature of Applicant: ____________________________________
Date this questionnaire completed: ______/_________/__________
1

Legal Name: Last, First, Middle Social Security #
Additional Names you may have been known as (maiden, nicknames, aliases, etc.)
Residence Address (Number, Street,
City, State, Zip)
Phone Numbers w/ Area Codes
Home:
Cell:
Other:
email:
Contact Person in case of Emergency and Phone Number and Relationship:
Ohio Driver’s License Number: _______________________________
Type: _____________________ Expiration:______/______/________
Is Your Driver’s License Valid? Yes No
Are you legally eligible for employment within the United States? Yes No
Has your Driver’s License ever been suspended or revoked? If YES, describe the
circumstances and the dates of occurrences:
Have you ever been involved in an automobile accident? If YES, describe the
circumstances and the date(s) on which the accident(s) occurred:
Do you have any hatreds or prejudices towards others because of their race, sex or national
origin, which would be detrimental to your functioning as a firefighter/EMT?
Do you have any problems controlling your temper?
2

Residence History
Addresses: For last ten (10) years, account for all time spans. Start with oldest address
first and ascending order thereafter, including all military addresses. If presently renting or
leasing, include the agent or company to whom you pay.
From:
Month/Year
To:
Month/Year
Address:
Street, City, State, Zip Code
Contact Name & Phone
Number of someone that
can verify residency:
3

Financial History
When answering the questions below, write in “yes” or “no”. If there are any answered
“yes”, explain fully on the continuation sheet, citing the section, page and question
numbers. Be complete on all explanations.
1. Do you have any immediate civil actions pending against you? Yes No
2. Have you ever been garnisheed, filed bankruptcy or been declared bankrupt? Yes No
3. Have you ever been bonded or had a bond refused? Yes No
4. If employed in the Fire Department, do you anticipate any income other than your
firefighter salary? Yes No
5. Are you now delinquent in any financial obligations? Yes No
6. Do your monthly payments exceed you take home pay? Yes No
7. If yes to questions #5 and #6, list your indebtedness below:
To Whom
Owed:
Address:
Date
Incurred:
Original
Amount:
Amount
Due:
Monthly
Payment:
4

Employment History
The following questions: Write in “yes” or “no”
1. Have you ever applied for a position with any Fire Department or Government Agency? ___
Name of
Dept./Agency
Date Applied Accepted If No, give reason for
rejections or
declination of position
2. Have you ever been discharged or asked to resign from a job? ______If Yes, explain on
continuation sheet
3. May we contact you present employer? ______ If No, explain on continuation sheet. If
presently employed, indicate under Present Employer.
PRESENT EMPLOYER
From Date: Name of Present Employer: Job Title:
To Date: Address of Present Employer: Description of Duties:
Length of
Employment:
Name of Immediate Supervisor:
Address of
Supervisor
Supervisor’s Phone
#:
Salary: Full Name of Co-Worker: Address of
Co-Worker:
Co-Worker’s Phone
#:
5

Begin with your OLDEST job and list your complete work history in chronological order.
INCLUDE IN SEQUENCE, ALL PART TIME JOBS, PERIODS OF UNEMPLOYMENT AND
MILITARY SERVICE. When listing military service, substitute the name and address of
“IMMEDIATE SUPERVISOR”, with the name, address and rank of the LAST
COMMISSIONED OFFICER who was your immediate commissioned superior and substitute
the “NAME AND ADDRESS OF CO-WORKER”, for the name and address of a NON-
COMMISSIONED OFFICER with whom you served. When listing periods of unemployment,
indicate dates in space provided. In that block designated “NAME OF EMPLOYER”, write in
“UNEMPOLOYED”. In the space designated for “REASON FOR LEAVING” indicate from
what source you received income during that period of unemployment.
From Date:
Name of Present
Employer:
Job Title
Reason for leaving
To Date:
Address of Present
Employer:
Description of Duties:
Length of Employment:
Name of Immediate
Supervisor:
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
6

From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
7

From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
From Date:
Name of Present
Employer
Job Title
Reason for leaving
To Date: Address of Employer Description of Duties
Length of Employment
Name of Immediate
Supervisor
Address of Supervisor Supervisor Phone #
Salary Full Name of Co-Worker Address of Co-Worker Co-Worker Phone #
8

Military History
Present Draft Board Address (Street City,
State, Zip)
Draft Board No. Presented/B Class
Branch of Service Unit when Discharged Military Serial Number
Military Active Duty Dates
(Don Not Include short Reserve tours of 90
days or less)
Highest Military Rank/ Rank Held
Total Months of Combat Duty
Total Months of Overseas
Duty
Military Reserve Status
□ Ready
□ Standby
□ None
Educational History
List each Grammar, Jr. High/ Middle School, High School, Trade, Part Time, Night School,
Business or College and University that you have attended. Start with the most recent school
attended.
Name Of School
Location of
School
(city,state)
Course of
Study
Years
Completed
Graduate
d
Degree
Or
Diploma
9

Criminal / Traffic History
For the following questions, answer “yes” or “no”
1. Have you ever been convicted of a felony? Yes No
2. Have you ever been convicted of any criminal offense? Yes No
(i.e. theft offenses, assault and batter, wrongful influence of a minor, disorderly conduct,
gambling, drug offense, sex offense, offense involving immoral or indecent conduct, fraud,
trespassing conversion of trust, offense involving military justice or any other criminal
offenses).
3. Have you ever been convicted of any traffic offense? Yes No
(i.e. operating a motor vehicle while under the influence of alcohol or drugs, reckless
operations, hit/skip, vehicular homicide, speeding, drag racing, willfully fleeing or eluding
police, operating an unsafe vehicle, driving without a license, passing a school bus, receiving
or discharging passengers, or any other traffic offense, excluding parking and equipment
violations).
4. Have you ever been committed to any penal institution for the conviction of either a felony
or misdemeanor? Yes No
If the answer to any of the above is “yes”, complete the following:
Date: Offense/Charge Police Agency
City, County, State
Disposition
Or Sentence
(If Additional Space is Required, Please add below)
10

References
Fill in below the names of three adults not related to you and not former employers,
who have known you for a period of preferably more than five (5) years.
1.) Name Home Address Home Phone #
Years Known
Business,
Occupation
Business Address Business Phone #
2.) Name Home Address Home Phone #
Years Known
Business,
Occupation
Business Address Business Phone #
3.) Name Home Address Home Phone #
Years Known
Business,
Occupation
Business Address Business Phone #
Continuation Sheet
NOTE: In utilizing this section to explain or further add to answers, MAKE
REFERENCES TO THE PARTICULAR SECTION, PAGE NUMBER AND QUESTION
NUMBER, IN THE COLUMN PROVIDED BELOW BEFORE PROCEEDING TO ANSWER.
Your answers must be clear in meaning, explain all facets of the particular question.
CAUTION: In signing the certificate on page 1, you are attesting to the validity of all
answers noted within this continuation, as well as all areas of this questionnaire.
Should you require further space, attach an 8 ½ X 11 inch sheet of plain paper.
11

Fire/EMS Certifications
Please list below all FIRE or EMS Certifications you obtain. Copies are needed also at time of
returning application to us. If you need more spaces attach sheet.
1. 2.
3. 4.
5. 6.
7. 8.
9. 10.
11. 12.
13. 14.
15. 16.
17. 18.
19. 20.
21. 22.
23. 24.
25. 26.
27. 28.
29. 30.
31. 32.
33. 34.
35. 36.
37. 38.
39. 40.
12

Release and Authorization for Public Records
To be used when procuring information from public records without the Services of a
Consumer Reporting Agency.
DISCLOSURE: A PUBLIC RECORD MAY BE PROCURED FOR EMPLOYMENT
PURPOSES ONLY.
I voluntarily and knowingly authorize, for employment purposes only, Greenfield
Township to obtain public records, which may include records documenting arrest,
indictment, conviction, civil judicial action, tax lien or outstanding judgments.
I voluntarily and knowingly release from all liability all persons, companies and
corporations requesting and/or supplying information for such public records, except
that such release shall not be implied to waive any rights I may have to correct errors
or misstatements contained in the public records obtained pursuant to this agreement.
Signature________________________________
Full Name(please print)
Date:____________________________________
Drivers License Number
Street Address
_________________________
State of Issue____________
Date of Birth
City, State, Zip Code
Social Security Number
Revised: June 2006. mls
13