WAUCONDA FIRE DISTRICT Applicant Handbook
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- Horatio Morris Bond
- 5 years ago
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1 Firefighter / Paramedic 2018
2 Overview of the Application Process The Fire District testing and hiring procedures are designed to meet the requirements of federal and state law and to ensure the best selection of new career members by providing a progression of testing and evaluation events established for the position of Probationary Entry- Level Firefighter/Paramedic. Step 1: Step 2: Step 3: Step 4: Step 5: Application Process Testing, Evaluation, and Preliminary Background Check Wauconda Fire District Fire Commission Interviews Background Investigation Medical Examination Candidates for the position of Firefighter/Paramedic must meet the minimum requirements as listed in the Wauconda Fire District s hiring standards. Application Process Applicant Qualifications: At least 21 years of age at the time of written exam and not older than age 35 at time of application, unless applicant falls under one of the statutory exceptions. A U.S. citizen at time of filing formal application or must meet requirements of Illinois Human Rights Act for citizenship status. Must have or be able to acquire a valid Class B Non-CDL Driver s License prior to date of hire. Must have a minimum of high school diploma or GED certificate. Must have the ability to understand the English language, both written and spoken. Must be a licensed EMT-B through the Illinois Department of Public Health at time of application. New employees must be licensed in State of Illinois as EMT-P (Paramedic) at time of hire. Must be certified as a Firefighter II / Basic Operations Firefighter in the State of Illinois at time of application or provide a transcript or certificate showing successful completion of a State of Illinois Firefighter II / Basic Operations Firefighter program. Must be of sound mental and physical health and meet all established standards. Must have CPAT Card issued within a 12 month period immediately preceding the date of the orientation. Must possess a valid CPAT card at time of hire. Must be able to pass a written test, oral interview, medical examination, drug test, and a background and security investigation. Must be able to work a typical schedule. Shift work is typically 24 hours on, 48 hours off, 0700 to 0700; as scheduled without regard for Holidays. All bargaining unit members must reside within Lake or McHenry Counties, Illinois, or any County adjacent to Lake or McHenry Counties. Page 2 of 29
3 Application Deadline: WAUCONDA FIRE DISTRICT Deadline for submitting applications is 3:00 p.m. on Monday, February 5, In the event of tie scores, placement on the Final Eligibility Register shall be assigned by lottery. Initial Testing and Evaluation: Event Date Time Location Application Deadline Mandatory Orientation February 5, 2018 February 17, :00 p.m. 9:00 a.m. Written Exam March 3, :00 a.m. Fingerprinting March 3, 2018 Fire Commission Interviews Initial Eligibility Register Posted Preference Points Due Final Eligibility Register Posted TBD April 26, 2018 May 11, 2018 May 24, 2018 After Written Exam As Assigned 5:00 p.m. 3:00 p.m. 5:00 p.m. Wauconda Fire District Station #1 109 West Liberty Street Wauconda, IL Wauconda Grade School 225 Osage Street Wauconda, IL Wauconda Grade School 225 Osage Street Wauconda, IL Wauconda Police Department 311 South Main Street Wauconda, IL Wauconda Fire District Station # South Gilmer Road Volo, IL Wauconda Fire District Station #1 109 West Liberty Street Wauconda, IL Wauconda Fire District Station #1 109 West Liberty Street Wauconda, IL Wauconda Fire District Station #1 109 West Liberty Street Wauconda, IL Posting of Eligibility Registers All Eligibility Registers will be posted at Wauconda Fire District Station #1, 109 West Liberty Street, Wauconda, IL In accordance with Illinois State law the Fire Commission may post a Preliminary or Initial Eligibility Register after the written exam or after the written exam and the Commission interviews. The decision as to when to post will be determined by the Commission after the results of the written exam are tabulated. Page 3 of 29
4 An Eligibility Register of all the applicants who passed all of said examinations will be posted after all applicants have completed the elements of any examination called by the Wauconda Fire District Fire Commission. Within 10 days after posting of the Initial Eligibility Register, applicants, who may claim a preference under the Illinois Board of Fire and Police Commissioner Act for military service, or educational achievement, or fire service training and service, shall make their claims or they shall be deemed waived. Evidence of qualification for such preference must accompany the claim. After receipt of a valid claim of preference from an applicant, the Secretary shall add the appropriate number of points to that applicant s examination score in accordance with the Act. After preference additions have been completed, the Secretary shall re-rank the applicants on the Initial Eligibility Register according to their scores and examinations, and the applicants order of eligibility as thereafter determined shall be the basis for placement of such applicants on a Final Eligibility Register. When notified of a vacancy, the Fire Commission will issue a letter to a candidate based on position on the Final Eligibility Register. The letter will indicate the scheduled appointment made for the candidate s Medical Examination. If the results of the Medical Examination are less than satisfactory, the candidate will be notified in writing of the results and the process will end for that candidate. If the results return as satisfactory, the process will continue, and the Background Investigation will be completed. Preference Points Experience Preference Points (maximum 5 points) Any applicant who has been a part-time certified Firefighter II / Basic Operations Firefighter, certified Firefighter III / Advanced Technician Firefighter, EMT-B, EMT-I and/or Paramedic of the WAUCONDA FIRE PROTECTION DISTRICT shall be awarded one-half (1/2) point for each year of successful service, up to a maximum of five (5) points at the time of the posting of the Initial Eligibility Register. Any applicant from outside the WAUCONDA FIRE PROTECTION DISTRICT who was employed as a full-time certified firefighter or paramedic for at least two (2) years at another fire protection district or municipality shall have the same preference as WAUCONDA FIRE PROTECTION DISTRICT part-time personnel and shall be awarded one (1) point for each year up to a maximum of five (5) points. No experience preference points will be awarded to applicants for service with a private employer who had a contract for fire or ambulance service with a fire protection district or municipality. Proof of such service must include submission of copies of applicable certificates and a sworn affidavit by the applicant (attached). Note that proof of part-time or full-time service may be verified by the District. Also note that an applicant may not receive experience preference points for a certificate if the amount of points awarded would place the applicant before a Page 4 of 29
5 veteran on the eligibility list. Finally, no person shall be awarded more than the maximum of five (5) points for experience. Veteran s Preference Points (maximum 5 points) Applicants who served in the United States military actively for at least one year and who were honorably discharged or are now on inactive or reserve duty shall receive five (5) points. Proof of such service must include a copy of Military Form DD-214 (long form) as proof of active service, evidence of the honorable discharge and a sworn affidavit by the applicant (Page 30). Educational Preference Points (maximum 5 points) Applicants who have successfully obtained an associate s degree in the field of law enforcement, criminal justice, fire service, or emergency medical services, or a bachelor s degree in any field from an accredited college or university shall receive five (5) points. Proof of such degree must include a copy of diploma. Paramedic Preference Points (maximum 5 points) Persons who have obtained certification as an Illinois Emergency Medical Technician Paramedic (EMT-P) shall receive five (5) preference points. A copy of a current IDPH paramedic license must be submitted as proof of the certification. Background Investigation Upon selection by the Commission, candidates must successfully complete a thorough personal background and security investigation which includes inquiries into criminal history, driving record, educational level, military service, credit history, references, moral character, and other areas outlined in the Rules and Regulations. Each qualified candidate is investigated as to character and reputation. The candidate s present and previous employer(s) may be contacted for information regarding work history, including police history. If the results of the Background Investigation are less than satisfactory, the candidate will be notified in writing of the results and the process will end for that candidate. Medical Examination Upon selection by the Fire Commission, certified candidates must successfully complete a two-part comprehensive medical examination / evaluation and drug screen prior to employment. The medical examination/evaluation will be administered by a physician group designated by the District that is capable of making a pre-employment judgment based on the NFPA 1582 Standard on Medical Requirements for Firefighters and Information for Fire Department Physicians. Page 5 of 29
6 Offers of employment are made contingent on the successful completion of a pre-employment medical evaluation and drug screen. Failure to successfully pass the medical evaluation and/or drug screen will result in the withdrawal of the qualified job offer. The Fire Commission will cover the initial cost of the medical examination / evaluation and the candidate is responsible for any subsequent elements required to confirm eligibility. Probation Period: Probationary period is twelve (12) months in length and during this period the following items must be completed: Certified EMT-P in the Condell Medical Center EMS System OSFM Certified Fire Apparatus Engineer Complete driver training on all District vehicles / apparatus Completion of Probationary Task Book During the probationary period, the employee may be suspended, laid-off, or terminated without cause at the sole discretion of the District. Items to be Returned: Only candidates with complete Application Packets returned to Wauconda Fire District Station #1 at 109 West Liberty Street, Wauconda, IL no later than 3:00 p.m. on February 5, 2018 will be considered to proceed with further testing. ALL Application Packets must include all of the following items with all waivers signed and witnessed as indicated on each form: Legible copy of current Driver s License Legible copy of Birth Certificate Legible copy of high school diploma or GED Certificate Legible copy of Military DD214 (if applicable) CPAT Certification Legible copy of IDPH EMT-B or EMT-P license Legible copy of State of Illinois Firefighter II / Basic Operations Firefighter certification or course completion documents Completed Application and Background Investigation Form Signed Voluntary Statement of Agreement, Waiver, and Indemnification Signed Test and Rules Property Signed Acknowledgement/Consent Background, Security, and Credit History Signed Release of Information One copy of any Fire or EMS related civil complaints where you were named as a defendant Page 6 of 29
7 No deviation or exception is accepted on any application requirement. Errors and omissions are the responsibility of the applicant. Postal service and application delivery confirmation is also the responsibility of the applicant. Application and Background Investigation The Wauconda Fire District considers all persons for employment without regard to race, color, religion, gender, age, physical disability, national origin, or any other legally protected status, in accord with all applicable legal requirements. Important Instructions - Read Carefully It is recommended that you read this entire booklet completely prior to completion as the information is extremely important. Type or print legibly in black ink all information requested. False, inaccurate, or incomplete information may subject you to disqualification or dismissal from the District. If space provided is inadequate, please provide information in the Continuation of Answers section. The background investigation is a phase of the selection process and your full cooperation is expected. Read every question carefully. Answer each question. Leave no blank spaces. Provide complete names, include middle name or initial. Addresses must include ZIP codes. Telephone numbers must include area codes. You, as the applicant, are required to obtain all information necessary to complete this booklet. You are also responsible for personally preparing the booklet and compiling all copies of the required documents. In the event more space is required, use a separate sheet of paper. This background investigation and its results are strictly confidential and are the sole property of the Wauconda Fire District Fire Commission. All copies of documents provided by the applicant become the sole property of the Wauconda Fire District Fire Commission and will not be returned. Keep pages 1 through 7 for your reference. Page 7 of 29
8 Firefighter / Paramedic Application Return pages 9 through 29 Page 8 of 29
9 Personal Information 1. Applicant Full Name: Last First Middle 2. Give any other name(s) you have been known by or used and attach a statement giving reasons, include maiden name, if applicable: _ 3. Place of Birth (Facility, City, County, State, Country): _ 4. Date of Birth (Month/Date/Year): 5. Social Security Number: 6. Please list your residences for the past 5 years, starting with your present address: From Month & Year To Month & Year Address City, State, Zip Code 7. Phone Numbers (include Area Code): Home: Work: Cell: 8. Do you have any relatives who are employed by the Wauconda Fire District? Yes No If Yes, list their name(s) and your relationship: _ Page 9 of 29
10 9. How did you learn of this position? WAUCONDA FIRE DISTRICT _ Personal History 10. Are you native born or a naturalized citizen? 11. If you are of foreign birth or a naturalized citizen, complete the following: Country of Birth: Port or Place of Departure for USA (Be Specific): Date of Departure for USA: Date and Port or Place of Entry into USA: If you are a naturalized citizen, give name and address of person who sponsored you on arrival into USA: First address after arrival in USA (include complete address with ZIP code): How did you obtain U.S. citizenship? Petition Number: Date: Court: State: Certification Number: Page 10 of 29
11 Education, Training, Experience 12. List schools (high school, college), special training (HazMat, Technical Rescue, Dive, Fire Investigation, etc.), or special skills training (trade schools or apprenticeships), with date(s) attended, and certificate(s) of accomplishments awarded. Certificate of Date(s) Type of School or Training Location Accomplishment 13. What professional license(s) do you possess? 14. Complete the required information in full: Item Number State, County, Country of Issue Driver's License Item License Plate Number State, County, Country of Issue Vehicle Vehicle Vehicle 15. Was your driver's license ever suspended or revoked, or have you ever been issued a judicial driving permit? Yes: No: If Yes, explain: Date of action: County, State, and Country of action: Page 11 of 29
12 Basic reason for action: 16. Have you ever obtained a driver s license under any other name? If Yes, please explain in detail: 17. Were your vehicle license plates ever suspended or revoked? Yes: No: If Yes, date of action: If Yes, explain in detail: 18. Have you ever been involved in a motor vehicle accident either as a registered owner, operator, passenger or pedestrian which resulted in any personal injury, property damage, or fatality to you or anyone else? Yes: No: If Yes, give full details, including city and state where occurred and police agency making any reports on incident: 19. Have you ever been convicted of any of the following? a. Involuntary manslaughter/reckless homicide. Yes: No: b. Leaving the scene of an accident involving property damage, injury or death. Yes: No: c. Driving under the influence of alcohol or drugs. Yes: No: d. Aggravated fleeing or eluding a police officer. Yes: No: e. Driving while license suspended or revoked. Yes: No: Page 12 of 29
13 f. Reckless driving. Yes: No: If you answered Yes to any of the above, please provide a detailed explanation including date(s), location(s), and nature of each incident. 20. Were you ever summoned or subpoenaed to court in a civil action in this state or elsewhere, or could such a possibility ensue as a result of a recent occurrence or transaction? Yes: No: If Yes, indicate below every civil action or proceeding in which you were a party to, past and/or present. Also if Yes, please explain all entries in detail on a separate piece of paper. Date Action Or Proceeding Plaintiff-Defendant Witness-Respondent Court Disposition 21. Do you possess an Illinois Firearm Owners Identification Card? Yes: No: 22. If Yes, what is your Firearm Owners ID Number: 23. Have you ever had a Firearms Owner ID Card Application rejected for any reason? Yes: No: If an application was rejected, why? 24. Have you ever had a Firearms Owner ID Card revoked for any reason? Yes: No: If Yes, why? Page 13 of 29
14 25. Do you now, or have you ever used, tried, or experimented with narcotics, marijuana, barbiturates, or any other illegal drug(s)? Yes: No: If Yes, be very specific as to what you used, how many times used, when, your age at time, and in what quantity: 26. Have you ever used prescription drugs not prescribed to you? Yes: No: If Yes, please explain: 27. Do you consume any alcoholic beverages? Yes: No: If Yes, what do you usually drink (beer, wine, etc.)? 28. If you consume alcoholic beverages, give an honest estimate of your weekly consumption: _ 29. Have you ever had any problems at all with alcohol consumption? Yes: No: If Yes, Give Details: Page 14 of 29
15 30. Have you ever had any work problems related to alcohol consumption? Yes: No: If Yes, Give Details: Military Service 31. Have you ever served in a military or naval organization of the United States of America? Yes: No: 32. Have you ever served in a military or naval organization of any foreign government? Yes: No: If Yes, give details: 33. Were you ever refused entry into any military or naval service? Yes: No: If Yes, give details: 34. How many periods of active military service have you served (include drafts, enlistments, and recalls to service)? 35. List below period(s) of active service and type discharge: From Month / Year To Month / Year Type Of Discharge Page 15 of 29
16 36. Has your discharge or separation ever been corrected or changed? Yes: No: If Yes, what was the nature of the change? 37. Give branch of military service you served in: 38. Military rank held: Service Serial #: If more than one period of military service, attach a separate sheet providing additional information. 39. Explain any military or naval discharge(s) other than Honorable. Please explain in detail in the Continuation of Answers section: 40. Were you ever court-martialed, tried on charges, or were you the subject of any other disciplinary action in the military? Yes: No: Number of times: If Yes, please explain in detail in the Continuation of Answers section and include the dispositions. 41. Are you now or were you ever an active or inactive member of any reserve forces of the United States of America or any foreign government? Yes: No: If Yes, state all details including country, active or inactive, branch, unit, your rank, and the dates of service: 42. Are you now or were you ever a member of the National Guard? Yes: No:. If Yes, answer the following: State: Regiment: Page 16 of 29
17 Unit: Rank: From: To: Type of Discharge: Employment History List your previous three (3) employers. Begin with your current or most recent employer. 43. Employer: Address: Telephone: ( ) Supervisor: name: Employed: Job Title: Duties: Why Left? From: : To: Salary: 44. Employer: Address: Telephone: ( ) Supervisor: Employed: From: To: Job Title: Duties: Why Left? 45. Employer: Address: Telephone: ( ) Salary: Supervisor: name: Employed: From: To: Job Title: Duties: Why Left? Salary: Page 17 of 29
18 46. Have you ever submitted an application for appointment to another Fire Department/District? Yes: No: Agency If Yes, please fill in the requested information below: Application Date Position Applied For Position on List 47. Have you ever been employed as a firefighter and/or paramedic? Yes: No: If Yes, please fill in the information below: Agency Position Dates of Employment Reason For Leaving 48. Are you a certified EMT-P? Yes: No: Are you a Certified Firefighter III / Advanced Technician Firefighter? Yes: No: 49. Have you ever been discharged or asked to resign from previous employment? If Yes, please explain in detail (including employer contact information): 50. Have you ever been bonded? Yes: No: If Yes, give complete details (amount of bond, by whom bonded, and reason for the bond): Page 18 of 29
19 51. Have you ever been refused a bond? Yes: No: If Yes, give complete details: 52. What is your current occupation? 53. State current monthly income: 54. Were you ever discharged or asked to resign from employment? Yes No How many times? If Yes, give details on separate sheet of paper including the name and address of employer, the date, superior s name, and the reason. 55. Were you ever subject to disciplinary action in connection with any employment? Yes No If Yes, give details: 56. Have you ever applied for a civil service examination, other than the one for which you are currently applying? Yes: No: If Yes, state year, locality, position and results: 57. Were you ever rejected for any civil service position? Yes: No: If Yes, give details. Page 19 of 29
20 58. Have you ever previously submitted an application for hiring to the Wauconda Fire District? Yes: No: If Yes, state year, list number, and results of your filing the application: References 59. List below your current, immediate neighbors. Print legibly and list them by name, address, ZIP code, and home phone number including area code. If you do not know your immediate neighbors, contact them and obtain this information. 1. Name Phone Address City State Zip Code 2. Name Phone Address City State Zip Code 3. Name Phone Address City State Zip Code 4. Name Phone Address City State Zip Code Page 20 of 29
21 60. List three (3) Personal References, references shall not be past and / or present employees of the Wauconda Fire District or family members of the applicant. 1. Name Years Acquainted Address City, State, ZIP Phone (home/cell) Work Phone 2. Name Years Acquainted Address City, State, ZIP Phone (home/cell) Work Phone 3. Name Years Acquainted Address City, State, ZIP Phone (home/cell) Work Phone 61. Do you have any knowledge or information, in addition to that specifically called for in the preceding questions, which is or which may be relevant, directly or indirectly, in connection with an investigation of your eligibility or fitness for a position with the Wauconda Fire District; including but not limited to knowledge or information concerning your character, physical or mental condition, temperance, habits, employment, education, subversive activities, family associates and friends, criminal record, traffic violations, residence, or otherwise? Yes: No: If Yes, give details. Page 21 of 29
22 Continuation of Answers Use the following pages to add any remarks to previous questions. Please correspond the answer with the question number: Page 22 of 29
23 Test and Rules Property I, the undersigned, understand that all tests and the rules thereof become the property of the Wauconda Fire District Fire Commission and are not subject to review. Date: Signature: Printed Name: Witnessed: Page 23 of 29
24 Acknowledgement / Consent for Background As part of the application process for employment with the Wauconda Fire District the undersigned applicant has been informed and understands that an investigation may be made whereby information is obtained through personal interviews with the applicant s neighbors, friends, or others with whom the applicant is associated or acquainted. This inquiry includes, as appropriate, information as to the applicant s character, general reputation, personal characteristics and mode of living. The applicant has the right, within a reasonable period of time, to make a request in writing to receive additional, detailed information about the nature and scope of this investigation. The undersigned agrees and consents to the release of such information to the Wauconda Fire District Fire Commission as the applicant s prospective employer. Signed at, on the day of (City and State) 20. Applicant Signature: Printed Name: Page 24 of 29
25 Background Investigation Authorization I understand that my background investigation, including a physical examination, consists of confidential material which will not be released to me. Furthermore, I hereby authorize the Wauconda Fire District Fire Commission to investigate records of my former employment and my acquaintances and references, past and present. This authorization includes the full release of all documents contained in personnel files of prior employers. I hereby release any person or persons providing or receiving such information from any and all liability for damages of whatever kind resulting to me, my heirs or assigns. Copies of this authorization may be provided to such employers and said copies may be treated as if they were signed originals. To Whom It May Concern: I respectfully request that you forward to the Wauconda Fire District any and all information that you may have concerning my work record, my reputation, or me. Also, please give any information that may appear in my personnel file. This information is to be used to determine my qualifications and fitness for the position I am seeking with the Wauconda Fire District. I hereby release you and/or your employer from any liability and damage of whatsoever nature, on account of furnishing the information requested above. Candidate Signature Printed Witness Signature Printed Date Page 25 of 29
26 Certification Statement I, (applicant's printed full name) personally read each and every question and answered each and every question in this background investigation booklet and questionnaire, and I do solemnly swear that each and every answer is full, true, and complete and correct in every respect. I fully understand that failure to complete and return this Application Background Investigation Authorization and failure to submit all copies of required documents in every respect as instructed and required, may be cause for my removal from the Wauconda Fire District Fire Commission Entry-Level Firefighter/Paramedic Final Eligibility Register. Applicant's Full Legal Signature: Applicant's Full Legal Printed Name: Date of Signature: Note: This background investigation booklet and any copies supplied for this background investigation are the sole property of the Wauconda Fire District Fire Commission and nothing will be returned to the applicant. For Office Use Only Received by the Wauconda Fire District Fire Commission: Date Received by (Printed) Time Received by (Signature) Page 26 of 29
27 WAUCONDA FIRE PROTECTION DISTRICT PREFERENCE POINT CLAIM FORM If you wish to claim preference point for the final eligibility register for hire with the WAUCONDA FIRE PROTECTION DISTRICT, please complete the following form and submit it with any required attachments within ten (10) days after the posting of the initial eligibility register. Failure to submit the request within ten (10) days shall be deemed a waiver of the points. A. Experience Preference Points (70 ILCS 705/16.06b(h)(5)) (max. 5 points) Please state the relevant dates of successful service in the following capacities and attached Firefighter II, Firefighter III, EMT-B, EMT-I and/or Paramedic certificates; do not include employment with any private company or service even if that employment provided service to a fire district or municipality. 1. WAUCONDA FIRE PROTECTION DISTRICT Paid-On-Call Firefighter, EMT and/or Paramedic (1/2 point for each year successful service up to 5) Date of Service (month/date/year): to OSFM / IDPH Certification Dates (month/date/year): FF II / BOFF: EMT-B/I/P: FF III / ATFF: OR 2. Full-Time Certified Firefighter and/or Paramedic A Fire Department other than Wauconda (for at least 2 years; 1 point/year up to 5 points) a. Name of Department/District: Address: Phone Number: Date of Service (month/date/year): to b. Name of Department/District: Address: Phone Number: Date of Service (month/date/year): to Page 27 of 29
28 B. Veteran s Preference Points (70 ILCS 705/16.06b(h)(1)) (max. 5 points) Please state the following information regarding your military service and attach form DD- 214 (long form) and proof of honorable discharge: a. Branch of Service: Unit: Rank: Date of Service (month/date/year): To Date of Honorable Discharge: C. Educational Preference Points (70 ILCS 705/16.06b(h)(3)(max. 5 points) Please state the following information regarding your educational service and attach a copy of your diploma: a. College or University: Degree attained: D. Paramedic Preference Points [70 ILCS 705/16.06b(h)(4)] (max. 5 points) Persons who have obtained certification as an Illinois Emergency Medical Technician Paramedic (EMT-P) shall receive five (5) preference points. A copy of a current IDPH license must be submitted as proof of the certification. License Number: Date first issued (month/date/year): Expiration Date (month/date/year): Please indicate your current resource hospital: Page 28 of 29
29 STATE OF ILLINOIS ) )SS COUNTY OF ) CANDIDATE S AFFIDAVIT I,, being first duly sworn on oath, Name of Candidate do hereby state that the information set forth in my WAUCONDA FIRE PROTECTION DISTRICT Preference Point Claim form is true and correct. I understand that any misrepresentation, falsification, or material omission may result in my application no longer being considered by the District, removal from the hiring list, and/or dismissal from the District. Candidate s Signature Subscribed and sworn to before me this day of, 20. Notary Public Date Initial Eligibility List was posted: Date of Submission of Claim form: Received by: For District Use Only Page 29 of 29
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