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Step One

FIREFIGHTER EMPLOYMENT APPLICATION and BACKGROUND INVESTIGATION
Human Resources City of New Smyrna Beach 210 Sams Avenue New Smyrna Beach, Florida 32168
Date of Application
Date of Application
How did you hear about this position?
1. City Website
2. Referral
3. Other
If Other
Position(s) Applied For
The City of New Smyrna Beach accepts applications at the time open positions are posted. Applications may be rejected if you do not complete the entire application form and provide the requested documents. Your application will be kept active for one year. If you wish to apply for other job openings within this one year period you may use the same application form by contacting Human Resources with your request at the time a new position is posted.
Last Name
First Name
Middle Initial
Address
City
State
Zip
Cell phone
Email address
Have you applied for a position here before?
1. Yes
2. No
Date When
Date When
Have you ever been employed here before?
1. Yes
2. No
Date When
Date When
Are you a lawfully eligible to work in the United States?
1. Yes
2. No
(Verification of eligibility will be confirmed upon employment)
Are you available to work?
1. Full Time
2. Part Time
3. Shift Work
Does the City of New Smyrna Beach employ any relative (by blood or marriage) or cohabitant of yours?
1. Yes
2. No
If yes, provide name, relationship and department where they work:
Name
Relationship
Dept. where employed
Name
Relationship
Dept. where employed
The City of New Smyrna Beach provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics.
In addition to federal law requirements, The City of New Smyrna Beach complies with applicable state and local laws governing nondiscrimination in employment in every location in which the City has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. The City of New Smyrna Beach expressly prohibits any forms of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, nation origin, age, genetic information, disability, or veteran status.
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Step Two

Step Three

Step Four

REFERENCES
FILL IN THE NAMES OF SIX (6) PERSONS NOT RELATED TO YOU, NOT FORMER EMPLOYERS, WHO HAVE KNOWN YOU INTIMATELY FOR A SUBSTANTIAL PERIOD, PREFERABLY MORE THAN FIVE (5) YEARS.
Name
Address
City
State
Zip
BUSINESS ADDRESS
BUSINESS PHONE
RESIDENTIAL PHONE
Name
Address
City
State
Zip
Business Address
Business Address
Residential Phone
Name
Address
City
State
Zip
Business Address
Business Phone
Residential Phone
Name
Address
City
State
Zip
Business Address
Business Phone
Residential Phone
Name
Address
City
State
Zip
Business Address
Business Phone
Residential Phone
Name
Address
City
State
Zip
Business Address
Business Phone
Residential Phone
THE FOLLOWING SPACE MAY BE USED FOR ADDITIONAL COMMENTS, REMARKS OR QUESTIONS TO BE ANSWERED.
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Step Five

List chronologically all of your residences for the past ten years, beginning with the most recent. Include addresses while attending school, if away from home, and all military addresses, including any off military base (use additional sheet if necessary).
Current Address
*If you currently reside in an apartment or rental home, list landlord information below:
City
State
Zip
Landlord Name
Phone Number
Date From
Date From
Address
Date From
Date From
City
State
Zip
Address
Date From
Date From
City
State
Zip
Address
Date From
Date From
City
State
Zip
Address
Date From
Date From
City
State
Zip
Address
Date From
Date From
City
State
Zip
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Step Six

CRIMINAL HISTORY
PLEASE ANSWER THE FOLLOWING QUESTIONS COMPLETELY AND ACCURATELY. ANY FALSIFICATION OR MISSTATEMENT OF FACTS WILL BE SUFFICIENT TO DISQUALIFY YOU.
yes or No check BoxHAVE YOU EVER BEEN CONVICTED OF A FELONY, OR, WITHIN THE LAST TEN (10) YEARS, A MISDEMEANOR WHICH RESULTED IN IMPRISONMENT AND/OR FINE?
1. Yes
2. No
If you mark "No" and Public Records indicate otherwise, you may be disqualified.
IF YES, LIST BELOW:
Nature Of Charge
AGENCY:
Date
Date
SENTENCE
Nature Of Charge
AGENCY
Date
Date
Sentence
Nature of Charge
AGENCY
DATE
DATE
Sentence
Nature Of Charge
AGENCY
Date
Date
Sentence
If Yes,
you must provide a full explanation on a separate sheet of paper. Conviction of a crime alone typically will not disqualify you from being considered for employment. Upon review factors taken into consideration may include nature of infraction, remoteness in time and rehabilitation.
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Step Seven

Step Eight

I acknowledge I have received a New Smyrna Beach Fire Department Job Description for the Firefighter / Paramedic position (document available on the job posting)
Signature
APPLICANT AFFIDAVIT
APPLICANT’S CERTIFICATION and AGREEMENT – THIS FORMS MUST BE NOTARIZED
Statement of Application:
I understand that previous employers will be contacted for references. I hereby authorize former employers to furnish any and all records of my service with them. I also release my former employers from any liability for any damage in providing this information. I also authorize educational institutions to furnish any records of education-related information they may have concerning me.
Status:
I understand that positions regarded as part-time and/or temporary are paid for actual hours worked and are not entitled to benefits offered to full time positions, with the exception of FICA and Worker’s Compensation.
Probation Period:
I understand that if hired, my position with the City of New Smyrna Beach is temporary during the established initial probationary period. My employment may be ended before the expiration of that period for any reason, without recourse.
Physical Examination/Drug/Alcohol Testing:
to take and pass a physical examination after an offer of employment is made and employment is contingent on the results of that examination in accordance with the Americans With Disabilities Act (ADA). I also understand that the post-offer physical, I will receive a copy of the City’s Drug-free Workplace Program. Any illegal or controlled substance that shows in my test results will cause my immediate disqualification for employment with the City of New Smyrna Beach.
Public Records:
Pursuant to Florida Statute 119, the Public Records Act, documents made or received by the City of New Smyrna Beach may be public record and open for inspection by the public. Some records, such as social security numbers, examination questions and answers and medical documentation are not public records and may not be disclosed.
Certification
I understand that this application must be completed in full. Incomplete applications may be rejected. I agree that any false or misleading information provided by me will be cause for canceling the application process. If hired by the City of New Smyrna Beach, after my hire date, it may cause my dismissal from City service. I have answered all the questions on this form completely and truthfully. I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. If hired, I agree to accept conditions of employment and abide by rules, procedures and policies of the City of New Smyrna Beach.
Release of Information:
By signing below you hereby authorize and give consent for the City of New Smyrna Beach to obtain information pertaining to possible criminal history on myself. This includes the following: Criminal Background Records/Information Sex Offender Registry Information, Addresses and Social Security Number Verification. I hereby release from liability and promise to hold harmless under any and all possible claims or causes of action (i) any and all persons or entities who shall furnish such information to the District, its officers, agents or employees, and (ii) the District, its officers, agents or employees for any statements, acts or omissions in the course of obtaining said information. Furthermore, I understand that this release is signed, free from duress, and with the full knowledge and understanding that any information obtained will be used in assessing my relative fitness for employment with the City of New Smyrna Beach.
Full Name
Date
Date
An applicant for the City of New Smyrna Beach Fire Department, do solemnly swear and attest to the correctness and truthfulness of all information contained in my employment application with the City of New Smyrna Beach, Florida. I further swear and attest that all information I have provided does not contain any deception misleading or false information, I also understand that should it be found that I have provided incorrect, untruthful, deceptive, misleading or false information, I will be terminated immediately from employment with the City of New Smyrna Beach.
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Step Nine

VETERAN’S PREFERENCE
This form must be completed if you wish to apply with Veteran's Preference
I am Claiming Veterans' Preference (Attach DD214 form)
Full Name
am claiming Veterans' Preference and certify that I am eligible to do so.
Branch of service
Type of Discharge
Date of Entry
Date of Entry
Date of Discharge
Date of Discharge
VETERAN’S PREFERENCE CRITERIA:
Under Florida law, preference in appointment and employment shall be given, by the State and its political divisions, to those persons with compensable service related disability eligible to or is receiving compensation, disability retirement, or pension under public laws administered by the U.S. Veteran’s Administration and the Department of Defense. Preference in employment, reemployment, promotion, and retention shall be given to an eligible veteran pursuant to ss. 295.07, 295.08, 295.085, and 295.09 as long as the veteran meets the minimum eligibility requirements and has the knowledge, skills, and abilities required for the particular position. If any applicant claiming Veteran’s Preference for a vacant position is not selected for the position, they may file a complaint with the Division of Veterans Affairs, P.O. Box 1437, St. Petersburg, FL 33731-1437. A complaint shall be filed within 21 days after notice of a hiring decision. If a notice of a hiring decision is not given, a complaint may be filed within three months of the date of application.
Are you claiming Veteran’s Preference as a: (Please check one)
1. Disabled veteran;
2. Spouse of totally disabled veteran or who is MIA; allowed for eligibility under this paragraph)
3. Veteran of any war, who has served at least one day during the following war time or who has been awarded a campaign or expeditionary medal, (Active duty for training shall not be allowed for eligibil
4. The unremarried widow or widower of a veteran who died of a service-connected disability.
5. The mother, father, legal guardian, or unmarried widow or widower of a service member who died as a result of military service under combat-related conditions as verified by the U.S. Department of Def
6. A Veteran as defined in section 1.01m [14] Florida Statutes. "Active Duty for Training" may not be allowed under this paragraph. The term "veteran" is defined as a person who served in the active mili
7. A current member of any reserve component of the U.S. Armed Forces or the Florida National Guard. Wartime periods are defined as follows:
World War II: December 7, 1941 to December 31, 1946 Korean Conflict: June 27, 1950 to January 31, 1955 Vietnam Era: February 28, 1961 to May 7, 1975 Persian Gulf War: August 2, 1990 to January 2, 1992 Operation Enduring Freedom: October 7, 2001 to TBD Operation Iraqi Freedom: March 19, 2003 to TBD Operation New Dawn: September 1, 2010 to TBD
Applicants claiming preference is responsible for providing the required documentation (DD214, Member letter) at the time of making an application for a vacant position.

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