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Employment Interest Form
Equal Opportunity Employer
In order to apply to become a firefighter, you must meet the following basic minimum qualifications:

Be at least twenty-one (21) years of age and not older than thirty-six (36) to receive a conditional offer: pursuant to IC 36-8-3.5-12

Be a citizen of the United States

Have a high school diploma or equivalent

Have and maintain a valid driver's license during the entire time you are in the process

Have NOT been convicted of a felony

Ability to read and write legibly, speak, understand, and otherwise communicate in the English Language

As a general rule, you must not have been dishonorably discharged from military service

Last Name
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First Name
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Middle Initial
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Address
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City
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State
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Zip Code
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Email Address
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Phone 1
(use xxx-xxx-xxxx format)
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Phone 1 Type
Phone 2
(use xxx-xxx-xxxx format)
Your answer
Phone 2 Type
Phone 3
(use xxx-xxx-xxxx format)
Your answer
Phone 3 Type
Date of Birth
MM
/
DD
/
YYYY
Are you a current member of the PERF-77 fund?
Do you have and will you maintain a valid Indiana driver's license?
Have you ever been convicted of a felony?
Are you a citizen of the United States or legally able to work in the United States?
Do you have a high school diploma or GED?
Acknowledgement
I understand I must participate in and pass all employment phases, including, but not limited to:

1.) This Applicant Basic Information Form which must be completed, submitted, printed and returned to Avon Fire Headquarters 311 Production Drive, Avon, IN 46123 by 4:00 pm on August 31, 2017. A $25.00 application fee (Cash or Cashier's Check only) must accompany the basic information form. Please make checks payable to the "Hendricks County Fire Chief Association".

2.) The Ladder Climb component will be held on September 16, 2017.

3.) The Written Examination will be held on September 23, 2017. A Valid Candidate Physical Ability Test (CPAT) Card is required in order to sit for the written test. A Candidate Physical Ability Test (CPAT) card may be obtained through ESEC on your own. To obtain more information on getting your CPAT card through ESEC you may visit www.wayne.k12.in.us/esec/ or call (317)-988-7703.

4.) An Oral Interview that will be scheduled during business hours the week of October 16, 2017.

5.) An extensive formal application which will be given to you at the oral interview

6.) A Background Investigation including drug screen

7.) A Medical and Psychological Examination

8.) Individual Fire Department or Territory Board Approval

* I understand arriving late to any scheduled event means I will be eliminated from the entire
process.
* I understand a valid personal identification is required at each phase of the process.
(i.e. driver’s license)
* By submitting this form, I certify the information contained on this form is correct to the
best of my knowledge. I realize my misrepresentation of the facts or my failure to update
any information contained on this form may be cause for rejection of this preliminary
application.
* By submitting this form, I affirm that I wish to be considered for employment as a Career
Firefighter and that I meet the basic minimum qualifications listed above.
* By submitting this form, I understand that if I am offered a conditional offer of employment
from any of the participating departments that I wil be removed from the hiring list
regardless of whether I accept or decline that offer.
* I agree to submit any change of name, address, or telephone number via email at:
hiring@brownsburgfire.org

How did you hear about this process? (optional)
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