Always Ready To Roll
Grand Caillou Volunteer Fire Department
Serving Our Community
GRAND CAILLOU FIRE DEPARTMENT
FIRE PROTECTION DISTRICT 4-A
Office: (985) 563-4112 6129 Grand Caillou Rd.
Fax: (985) 563-4114 Houma, LA 70363
WHEN RETURNING YOUR APPLICATION FOR EMPLOYMENT, PLEASE ATTACH THE FOLLOWING:
A COPY OF YOUR:
1. SOCIAL SECURITY CARD
2. DRIVER'S LICENSE
3. GRADUATION DIPLOMA OR GED CERTIFICATE
4. TRAINING CERTIFICATIONS OR CERTIFICATES
5. IN HOUSE TRAINING
6. ANY OTHER TRAINING
THANK YOU!
SINCERELY,
FIRE CHIEF
SHAWN BUMM
FIRE PROTECTION DISTRICT 4-A
Office: (985) 563-4112 6129 Grand Caillou Rd.
Fax: (985) 563-4114 Houma, LA 70363
WHEN RETURNING YOUR APPLICATION FOR EMPLOYMENT, PLEASE ATTACH THE FOLLOWING:
A COPY OF YOUR:
1. SOCIAL SECURITY CARD
2. DRIVER'S LICENSE
3. GRADUATION DIPLOMA OR GED CERTIFICATE
4. TRAINING CERTIFICATIONS OR CERTIFICATES
5. IN HOUSE TRAINING
6. ANY OTHER TRAINING
THANK YOU!
SINCERELY,
FIRE CHIEF
SHAWN BUMM
GRAND CAILLOU FIRE DEPARTMENT
FIRE PROTECTION DISTRICT 4-A
EMPLOYMENT APPLICATION
I. PERSONAL DATA (please print)
Name: ____________________________________________DOB:___________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Sex:_______ Race:_______ SS #_______________________
Driver's License No._________________________________ State Issued:______________
Place of Birth:______________________________________________________________
(City) (State) (Parish/Country)
Have you filed an application with this office before?__________
If Yes, give date____________________________________________________________
Have you ever been employed here before or a member of the volunteers?__________
If Yes, give dates___________________________________________________________
Are you legally eligible for employment in this country?__________
Date available for work?______________________________________________________
Will you be available to work any shift?_________
Type of employment desired: _______Full Time _______Part Time _______Relief
Are you on a lay-off and subject to recall?_________
Have you ever had any civil or criminal suits filed against you?_________
Have you ever been arrested?__________(if yes explain in section IV)
Have you ever been convicted of a misdemeanor?__________
Have you ever been convicted of a felony?__________
II. EDUCATION
Highest Grade Completed:___________ High School Diploma or GED:______________
College:____Yes____No If Yes list your Major_________________Minor_______________
Other School:_______________________________________________________________
If you did not graduate from a high school, did a State Board of Education issue you a high school equivalency certificate:_______ (If yes please provide the information below)
__________________________________________________________________________
(Issuing State) (Date Issued)
III. EMPLOYMENT
List your complete work history, INCLUDING MILITARY SERVICE, starting with your present employer first. Include any part-time employment and/or periods of unemployment.
1. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
2. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
3. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
4. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
5. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
IV. ARRESTS AND SUMMONS
(If you answered yes to the question about being arrested in section I, please provide information below)
Date Violation or Charge City & State Final Disposition Arresting Agency
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Has your driver's license or vehicle license ever been denied, suspended or revoked?
______Yes_______No (if yes please provide information below)
Details:____________________________________________________________________
Has your license been reinstated?_____Yes_____No Date of Reinstatement:_____________
Were you ever involved in a motor vehicle accident, as the driver?_____Yes_____No
Details:____________________________________________________________________
__________________________________________________________________________
V. JOB QUESTION
What is the reason you believe you would be good at the position you have applied for?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Is there any reason you believe you could not perform the duties of the position that you have applied for?________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
VI. REFERENCES
Give three (3) references, not related by blood or marriage, not mentioned previously, not former
employers or school teachers, who are responsible adults of reputable standing in their
community, who have known you well for at least five (5) years. (These references may include,
but are not limited to property owners, clergy and businessmen and women.)
1. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
2. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
3. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
4. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
5. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
Do you have any relatives or friends who are presently employed and/or have been employed by Fire Protection District 4-A? If yes list below:
Name Job Title Relationship
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Signature of Applicant:_________________________________Date:___________________
FIRE PROTECTION DISTRICT 4-A
EMPLOYMENT APPLICATION
I. PERSONAL DATA (please print)
Name: ____________________________________________DOB:___________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Sex:_______ Race:_______ SS #_______________________
Driver's License No._________________________________ State Issued:______________
Place of Birth:______________________________________________________________
(City) (State) (Parish/Country)
Have you filed an application with this office before?__________
If Yes, give date____________________________________________________________
Have you ever been employed here before or a member of the volunteers?__________
If Yes, give dates___________________________________________________________
Are you legally eligible for employment in this country?__________
Date available for work?______________________________________________________
Will you be available to work any shift?_________
Type of employment desired: _______Full Time _______Part Time _______Relief
Are you on a lay-off and subject to recall?_________
Have you ever had any civil or criminal suits filed against you?_________
Have you ever been arrested?__________(if yes explain in section IV)
Have you ever been convicted of a misdemeanor?__________
Have you ever been convicted of a felony?__________
II. EDUCATION
Highest Grade Completed:___________ High School Diploma or GED:______________
College:____Yes____No If Yes list your Major_________________Minor_______________
Other School:_______________________________________________________________
If you did not graduate from a high school, did a State Board of Education issue you a high school equivalency certificate:_______ (If yes please provide the information below)
__________________________________________________________________________
(Issuing State) (Date Issued)
III. EMPLOYMENT
List your complete work history, INCLUDING MILITARY SERVICE, starting with your present employer first. Include any part-time employment and/or periods of unemployment.
1. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
2. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
3. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
4. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
5. From_______________To_______________ Full Time_______ Part Time_______
Position(s) Held:____________________________________________________________
Company Name:____________________________________________________________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Immediate Supervisor:_________________________Phone Number:___________________
Reason for Leaving:__________________________________________________________
IV. ARRESTS AND SUMMONS
(If you answered yes to the question about being arrested in section I, please provide information below)
Date Violation or Charge City & State Final Disposition Arresting Agency
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Has your driver's license or vehicle license ever been denied, suspended or revoked?
______Yes_______No (if yes please provide information below)
Details:____________________________________________________________________
Has your license been reinstated?_____Yes_____No Date of Reinstatement:_____________
Were you ever involved in a motor vehicle accident, as the driver?_____Yes_____No
Details:____________________________________________________________________
__________________________________________________________________________
V. JOB QUESTION
What is the reason you believe you would be good at the position you have applied for?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Is there any reason you believe you could not perform the duties of the position that you have applied for?________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
VI. REFERENCES
Give three (3) references, not related by blood or marriage, not mentioned previously, not former
employers or school teachers, who are responsible adults of reputable standing in their
community, who have known you well for at least five (5) years. (These references may include,
but are not limited to property owners, clergy and businessmen and women.)
1. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
2. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
3. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
4. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
5. Name:________________________________________ Years Known:______________
_________________________________________________________________________
(Address) (City) (State) (Zip)
Phone Numbers:____________________________________________________________
(Home) (Cell) (Other)
Place of Employment:________________________________________________________
Do you have any relatives or friends who are presently employed and/or have been employed by Fire Protection District 4-A? If yes list below:
Name Job Title Relationship
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Signature of Applicant:_________________________________Date:___________________