14. EDUCATION AND TRAINING CHECK HIGHEST GRADE COMPLETED GRADE SCHOOL HIGH SCHOOL COLLEGE GRADUATE SCHOOL

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1 APPLICATION FOR EMPLOYMENT City of Salisbury Human Resources Department 125 N. Division St., Salisbury, MD Fax: website: We appreciate your interest in employment with the City of Salisbury and assure you that we are interested in your qualifications. The information requested in this application will aid us in evaluating your qualifications. Qualified applicants are considered without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, genetic information or presence of a medical condition or handicap. 1. Name (Last, First, Middle) 5. Position you are applying for Address: Number & Street City, State, & Zip Code 6. Date of Application 7. Date available to work 2. Social Security Number 8. Lowest pay you will accept 3. Home Phone: (Include Area Code) 9. Are you legally authorized to accept work and remain in the United States? 4. Business Phone: (Include Area Code) Yes No (Proof of identity and authorization will be required upon employment) 10. Are you currently 18 years or older? Yes No If not, state your age: 11. Licenses: Do you have a valid Driver's License? Yes No Driver License # State: Expiration Date: Type of License: Commercial Non Commercial Class: List all other professional licenses, registrations, and certificates: Type: Number: Expiration Date: Type: Number: Expiration Date: 12. List all machines or equipment, including office equipment, you can operate skillfully. 13. List all additional qualifications & skills: 14. EDUCATION AND TRAINING CHECK HIGHEST GRADE COMPLETED GRADE SCHOOL HIGH SCHOOL COLLEGE GRADUATE SCHOOL High School Name College Name City State City State Did you graduate? Yes No Did you graduate? Yes No Or Degree(s) Do you have a G.E.D. or equivalent? Major Minor Yes No Hrs. Completed In this space, list additional training and education completed. 15. References. List three persons who are not related to you and who have knowledge of your qualifications. Do not repeat supervisors listed under Experience Item 16. Name Address Phone

2 16. Experience. Starting with your current or most recent job, list all positions you have held in the last ten years. If you consider it appropriate to this application, you may include as an addendum, positions held earlier than ten years ago. Be concise, but do not omit information, which may be relevant to the position for which you are applying. If you nee d additional blocks, use blank sheets. A. Dates of Employment Job Title Number of Persons Supervised From: To: Salary: Hrs. Per Week Name of Supervisor Area Code and Phone Name and Address of Business or Employer: Reason for Leaving: May we contact this employer? Description of duties: If not, why not? B. Dates of Employment Job Title Number of Persons Supervised From: To: Salary: Hrs. Per Week Name of Supervisor Area Code and Phone Name and Address of Business or Employer: Reason for Leaving: May we contact this employer? Description of duties: If not, why not? C. Dates of Employment Job Title Number of Persons Supervised From: To: Salary: Hrs. Per Week Name of Supervisor Area Code and Phone Name and Address of Business or Employer: Reason for Leaving: May we contact this employer? Description of duties: If not, why not? D. Dates of Employment Job Title Number of Persons Supervised From: To: Salary: Hrs. Per Week Name of Supervisor Area Code and Phone Name and Address of Business or Employer: Reason for Leaving: May we contact this employer? Description of duties: If not, why not? 17. Military Service Yes No Branch of Service Serial or Service No. Dates of Service From: To: Did your military service have any relationship to the position for which you have applied? Yes No If yes, please explain 18. Are you related by blood or marriage to any City employee(s)? Yes No If yes, complete the following: Name Department Relation REV 8/3/2010

3 19. Have you been employed with us before? Yes No 20. How did you hear about this job? If Yes, answer questions below: A. Dates of Employment : From To: B. Position Held C. Reason for leaving: 21. Are you able to perform all of the duties and meet all of the requirements as listed in th e job ad for the job which you are applying (listed in section 5) with or without accommodations? Yes No 22. Have you ever been convicted of a crime including DUI or DWI? Yes No If yes, describe the conviction, when it occurred, the facts and circumstances, and any facts pertaining to rehabilitation? (Do not list any criminal conviction which has been expunged. A criminal conviction will not necessarily bar employment). a. b. c. d. PLEASE READ CAREFULLY Under Maryland law an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment, except law enforcement officers as defined in 727 of Article 27, or any employee of any law enforcement agency of the State of Maryland, or any county incorporated city or town, or other municipal corporation. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100. In submitting this application for employment, I authorize investigation of all statements contained therein. I hereby authorize the City of Salisbury to make any contacts considered necessary to my employment, such as previous employers, criminal or credit bureau records. I authorize any person or organization whose name I have given as a character reference or by whom I have been previously employed and any educational institution which I have stated I attended to furnish the City any information they may have concerning me. I hereby release all such persons, organizations, and institutions from any claims for damages or otherwise by reason of furnishing such information and records. It is understood and agreed that any misrepresentations or omissions by me in this application will be sufficient cause for cancellation of the application or the separation from City employment. I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for substance abuse. I also understand and agree that, if employed, I may be required to submit to an alcohol or substance abuse screening as required by law and City Policies and Procedures. I hereby consent to having the results of any such alcohol or substance abuse screening I may be required to undergo disclosed to City Government. I understand that this application is the property of City Government and will be part of my personnel file if I am accepted for employment. Driving record checks may be required of an applicant or employee who may be required to operate a City or personal vehicle on City business. This will also depend on the nature of the position and the insurance company's requirements. I hereby authorize the City to obtain a complete driving history. Any applicant who is selected for employment by the City of Salisbury must, as a condition of employment and before any offer of employment can be considered final, complete United States Department of Justice Immigration and Naturalization Service Form I-9 and provide acceptable documents that establish both identity and employment authorization as defined by Federal Regulation. The foregoing must be accomplished before employment and failure to do so will cancel any offer of employment with the City of Salisbury. The proposed employee has 5 working days within which to comply with these requirements. Acknowledged and Understood: Signature An Equal Opportunity Employer Date REV 8/3/2010

4 Not as a requirement and on a voluntary basis, use this page to provide any additional information helpful in evaluating your qualifications. Also, we welcome your comments on our job ads and employment process. REV 8/3/2010

5 Application Packet Position: Firefighter / EMT Firefighter / Paramedic

6 Table of Contents Letter from the Chief of the Department 2 Overview of Application Process 3 Application Component 4 Testing & Evaluation Component 5 Conditional Offer of Employment Letter 7 Background Investigation Component 7 Medical Evaluation Component 8 Interview Component 8 Appendix A - Forms and Supplementary Materials 9 Waiver of Liability for Physical Agility Assessment 14 Application Flow Chart 15 Process Check off List 16 1

7 JAMES IRETON, JR. MAYOR JOHN R. PICK CITY ADMINISTRATOR LORÉ L. CHAMBERS ASSISTANT CITY ADMINISTRATOR RICK HOPPES FIRE CHIEF MARYLAND 125 NORTH DIVISION STREET SALISBURY, MARYLAND Tel: Fax: Dear Applicant, Thank you for applying as a career Firefighter/EMT and/or Firefighter/Paramedic with the City of Salisbury Fire Department. There are several things that you need to know. Appointments to the Department are probationary for a period of one (1) year. During this first year, you must demonstrate your fitness and proficiency for continued employment with the Department. You must also understand that regular duty shifts include daytime and nighttime hours that have been established. Applicants may be assigned to a shift that involves these varying work hours. On occasions off-duty personnel may be recalled to duty to help at large scale incidents. As an integrated fire and emergency medical services system, all career personnel are required to maintain training, proficiency and participate in both fire and medical services. Appointment to the Salisbury Fire Department is contingent upon the results of a complete character and background investigation. A physical fitness examination and a drug and alcohol test will be required. Applicants must be advised that willfully withholding information or making false statements on the application and associated forms will result in the rejection of the applicant or if appointed, will result in the termination of the applicant's employment with the Department. All applicants must understand and agree to the conditions of employment and will certify that all statements are true to the best of their knowledge and belief. The applicant's signature on this application indicates such an agreement. Each applicant will be tested, investigated, interviewed and evaluated by Social Security Number. Best wishes on your pursuit of a career in emergency services. Sincerely, Richard A. Hoppes Richard A. Hoppes Chief of the Department 2

8 Overview of the Application Process The process to select new career members provides a step-by-step approach as detailed in this packet. This process is essentially a multi-faceted progression of testing and evaluative events that have been established to select the best applicants for the position of Firefighter/EMT-B and/or Firefighter/EMT-P. The process is as follows: Step 1: Application Process Step 2: Testing and Evaluation Step 3: Conditional Offer of Employment Letter Step 4: Background Investigation Step 5: Medical Evaluation Step 6: Interview with the Chief of the Department Detailed explanations follow for each of these steps in the process. Each applicant must read and understand each of the components to enable you to be in the best position for receiving a job with the Salisbury Fire Department. As with most of the hiring and appointment processes for a position in Public Safety and Emergency Services, the process to become a Firefighter/EMT or Firefighter/Paramedic with the City of Salisbury Fire Department is quite extensive. The process is designed to identify, and ultimately hire, the best possible applicants to become career members. 3

9 Application Component Every year, on or about the month of January, the application process will begin with advertisement for the positions of FF/EMT-B and FF/EMT-P. This will occur even when a hiring list has eligible applicants still in place from the previous year. If an eligibility list has been exhausted, a new process may take place when there is a need for filling positions within the Department. Eligibility lists are typically only good for a one (1) year period. Advertisement may be done in Trade Publications, Local Media, Job Fairs, and Placement Agencies. Application packets can be obtained in person, or requested, at the Human Resources Office located at 125 N. Division St. Salisbury, MD 21801, or on-line at either or All documentation below must be provided to the Chief s Office prior to receiving a conditional offer of employment. If you have these documents please provide with your application. 1. Copy of Birth Certificate 2. Copy of High School Diploma or G.E.D. 3. Copy of Military Discharge (if applicable) 4. Certified copy of Driving Record 5. Copy of Class C or higher Driver s License 6. Copy of Firefighter I -MFRI card is acceptable 7. Copy of current EMT-B or EMT-P License not just a MFRI card! 8. Copy of current AHA CPR Card 9. Copy of current ACLS Certification (if applicable) 10. Copy of Haz-Mat Operations level training MFRI card is acceptable. 11. Copy of MFRI Emergency Vehicle Operators Course (EVOC) card. (* Must obtain within 1 year of hire date) 4

10 Testing & Evaluation Component Written Assessment: Each applicant must successfully complete a written, multiple-choice examination. The Written Assessment evaluates each applicant s abilities in his/her: Ability to learn, remember, and apply information. Reading comprehension. Interests. Situational judgment. Logical and Mathematical reasoning ability. To successfully complete the Written Assessment the applicant must score at least 70%. Applicants with a score of 69% or less on the Written Assessment shall be considered unsuccessful and not move on in the testing process. Medical and Trauma Skills Assessment: Applicants that successfully complete the Written Assessment will be required to complete a Medical and Trauma Skills Assessment. The skills portion of this test is to evaluate the applicant s knowledge of patient assessment and management techniques and their knowledge of National Registry Skills and the Maryland Medical Protocols for EMS Providers. (This portion of the test shall have an ALS version and a BLS version.) Applicants that do not successfully complete the Medical and Trauma Skills Assessment shall be considered unsuccessful and not move on in the testing process. To successfully complete the Medical and Trauma Skills Assessment score at least 70%. the applicant must Applicants with a score of 69% or less on the Medical and Trauma Skills Assessment shall be considered unsuccessful and not move on in the testing process. See Appendix A for a copy of the Medical and Trauma Skills Assessment events. 5

11 Testing & Evaluation Component (Continued) Physical Agility, Strength, and Endurance Assessment: Applicants that successfully complete the Medical and Trauma Skills Assessment will be required to complete a Physical Agility, Strength, and Endurance Assessment. Each event is timed and a maximum allotted time is given for each event. All events in this assessment shall be spaced four (4) minutes apart; the maximum allotted time shall be included inside the four (4) minute spaces. Applicants that do not complete an event within the maximum allotted time shall be stopped and scored as unsuccessfully completing the assessment and not move on in the testing process. See Appendix A for a copy of the Physical Agility, Strength, and Endurance Assessment events. Oral Assessment: Applicants that successfully complete the Physical Agility, Strength, and Endurance Assessment shall be evaluated on their oral skills by sitting before a panel to respond to questions. Each applicant will be given a score for their responses by each panelist, which constitutes his/her score for the Oral Assessment. The scoring range is as follows: 1 = Extremely Qualified 2 = Very Qualified 3 = Qualified 4 = Less Qualified 5 = Not Qualified Applicants that are rated at Not Qualified shall be graded as unsuccessfully completing the Oral Assessment and not move on in the testing process. The Oral Assessment shall not take place on the same day as the Physical Agility, Strength, and Endurance Assessment. 6

12 Conditional Letter of Employment Component When a vacancy in the department occurs, the Chief of the Department, or his designee, shall issue a Conditional Letter of Employment to the applicant(s) that is/are the highest ranked on the list. This letter is not and should not be perceived as a guarantee of employment. This letter is to notify the applicant that there is a vacancy and that he/she shall begin the next steps toward employment with the Salisbury Fire Department. At the issuance of this letter, the Background Investigation & Medical Evaluation Components shall begin to take place. If the results of these components return as satisfactory, the process shall continue for the applicant(s). If the results are less than satisfactory the applicant shall be notified in writing of the results and the process shall end for that applicant. Background Investigation Component Upon receipt of the Conditional Letter of Employment, the Background Investigation Component shall begin. Included in the letter is a release for the Background Check to start. The applicant must sign and return this release for the process to proceed. The Background Investigation consists of the following components: Criminal Record Check conducted through the Maryland State Police and Maryland State Fire Marshal s Office. Finger Print Supported Criminal Background Check. Motor Vehicle Administration Records Check. Credit History Check. Personal References Check. Employment References Check. If the result of this component returns as satisfactory, the process shall continue for the applica nt(s). If the results are less than satisfactory the applicant shall be notified in writing of the results and the process shall end for that applicant. 7

13 Medical Evaluation Component All applicants must submit to a Medical Evaluation prior to employment. The Medical Evaluation shall be administered by a physician selected by the Department 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 standard. The Department shall cover the cost of the Medical Evaluation and is responsible for any element that pertains to the evaluation for the purpose of hiring an applicant. Interview Component Prior to employment, the Chief of the Department or his designee, shall interview all applicants. The purpose of this interview is to outline the terms of employment, as well as individual expectations upon taking a job with the Department. 8

14 Appendix A Forms & Supplementary Materials Medical and Trauma Skills Assessment Physical Agility, Strength, & Endurance Assessment Waiver of Liability for Physical Agility Assessment Application Flow Chart Process Check off List 9

15 Salisbury Fire Department Medical and Trauma Skills Assessment The skills assessment test is structured as follows: BLS: Cardiac Arrest Management with an AED Trauma Assessment & Management Seated Spinal Immobilization Oral Questions A LS: Adult Dynamic Cardiology Trauma Assessment & Management Seated Spinal Immobilization Oral Questions This assessment is based upon the current edition of the Maryland Medical Protocols for EMS Providers and the National Registry of Emergency Medical T echnicians, which can be located at and 10

16 Salisbury Fire Department Physical Agility, Strength, & Endurance Test Running Simulates the demand for cardiovascular and pulmonary fitness needed for personnel using Self Contained Breathing Apparatus (SCBA). The applicant shall run a one-half mile course in the allotted time frame. Bent knee Sit-ups Push-ups Maximum allotted time = 4 min. Simulates the person s core strength, which is required to perform the daily duties as outlined by the Salisbury Fire Department. The applicant shall perform thirty-five (35) bent knee sit-ups. Maximum allotted time = 90 sec. Simulates the personnel s need to push, as may be required to perform tasks; such as utilizing Pike Poles, Battering Rams, and performing Cardio Pulmonary Resuscitation (CPR). The applicant shall perform twenty (20) push-ups without stopping. Maximum allotted time = 1 min. 11

17 Salisbury Fire Department Physical Agility, Strength, & Endurance Test (Continued) Stretcher Lift Simulates the personnel s need to lift, as may be required to perform tasks; such as placing patients on and off of stretchers and placing stretchers in and out of ambulances. The applicant, with the assistance of qualified personnel shall lift from floor level, a Rescue Manikin secured to a Long Board weighing approximately 185 pounds and place onto a manually operated Stryker stretcher. The applicant shall then, with the assistance of qualified personnel, raise the stretcher and properly place, lock, and secure the stretcher into an ambulance. The applicant shall then, with the assistance of qualified personnel, remove the stretche r from the back of the ambulance, lower the stretcher to its lowest level and place the Rescue Manikin back on the floor. Maximum allotted time = 2 min. Stair Climb Simulates the personnel s endurance in working in fire and medical related incidents. The applicant shall ascend and descend six (6) flights of stairs while carrying a Salisbury Fire Department Airway Bag, Back Board, and Back Board Accessories Bag. Maximum allotted time = 90 sec. 12

18 Salisbury Fire Department Physical Agility, Strength, & Endurance Test (Continued) Ladder Raise Simulates the personnel s ability to raise ladders and lift or pull equipment, ropes, or other tools. The applicant shall raise a 24 foot extension ladder from a horizontal position on the ground to a vertical position. While qualified personnel stabilize the ladder, the applicant shall pull the halyard hand over hand, thereby fully extending the fly section of the ladder. The applicant shall then place the ladder against a fixed structure and obtain the proper climbing angle. The applicant shall then place the ladder back to a vertical position, then, pull the halyard hand over hand, thereby lowering the fly section to its bedded position and then lower the ladder to its original horizontal position on the ground. Aerial Ladder Climb Maximum allotted time = 2 min. Simulates the personnel s ability to maintain balance while ascending and descending an aerial ladder, as well as the ability to perform from ladders effectively without undue fear. The applicant shall ascend and descend an aerial ladder approximately five (5) stories. Maximum allotted time = 2 min. 13

19 Salisbury Fire Department RELEASE AN D WAIVER OF LIABILITY FOR PHYSICAL AGILITY, STRENGTH, AND ENDURANCE ASSESSMENT Name: SSN#: Date: I,, individually and on behalf of my heirs, executors, administrators, agents, successors and assigns (Releasor) for good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, hereby remise, release and forever discharge the City of Salisbury and the City of Salisbury Fire Department to whom the undersigned has applied for employment, and all of their respective officers, directors, employees, representatives, agents, attorneys, successors and assigns (hereinafter collectively referred to as Releasees) of and from any and all debts, demands, actions, causes of action, covenants, contracts, controversies, agreements, promises, omissions, damages, executions, claims, rights, liabilities, suits, sums and sums of money, rights to attorneys fees and extents whatsoever both at law and equity, now existing, or which may result from the existing state of things, including, but not limited to, all claims for injury, damages, personal injury, death, disability, loss of earning capacity, loss of consortium, and conditions incurred, during, or a result of my participation in the Physical Agility, Strength, & Endurance Assessment for the Salisbury Fire Department, for the purpose of demonstrating my abilities to perform certain physical tests, as a prerequisite to employment as a Firefighter/EMT with the City of Salisbury Fire Department. I acknowledge that I have reviewed and understand the requirements and descriptions for each and every separate physical test comprising the Physical Agility, Strength, & Endurance Assessment for the Salisbury Fire Department that I will be required to perform, and do hereby state that I am not aware of any physical or medical condition that will be aggravated, worsened or otherwise adversely affected by the strenuous nature of these tests and that I have fully and adequately prepared myself to take such tests before attempting any of them. I DO HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND REVIEWED THIS RELEASE AND WAIVER OF LIABILITY FORM AND FULLY UNDERSTAND, AGREE WITH, AND VOLUNTARILY ACCEPT THE TERMS AND CONDITIONS THAT HAVE BEEN OUTLINED ABOVE AND THAT I AM OVER THE AGE OF 18 YEARS, OF SOUND MIND AND AM SIGNING IT VOLUNTARILY. Signature: Date: Witness: 14

20 Salisbury Fire Department Application Flow Chart Advertisement for Position Application Process Testing Process Conditional Letter of Employment Background Investigation Medical Evaluation Psychological Evaluation Department Interview 15

21 Salisbury Fire Department Process Check off List Employment Application Completed Copy of Birth Certificate Copy of High School Diploma or G.E.D. Copy of Military Discharge (if applicable) Certified copy of Driving Record Copy of Class C or higher Driver s License Copy of Firefighter I (minimum) Pro-Board Certification not just a MFRI card! Copy of current EMT-B or EMT-P license not just a MFRI card! Copy of current AHA CPR Card Copy of current ACLS Certification (if applicable) Copy of Haz-Mat Operations level training MFRI card is acceptable. Copy of MFRI Emergency Vehicle Operators Course (EVOC) card. (* Must obtain within 1 year of hire date) 16