CIVIL SERVICE EXAMINATION FIREFIGHTER EMT/PARAMEDIC CITY OF FRANKLIN, OHIO Dear Career Firefighter/EMT/Paramedic Candidate, Thank you for your interest in becoming a career member of the City of Franklin, Division of Fire & EMS. This letter provides you with needed information regarding the selection process. Please review all of the following information carefully. You will have two opportunities to attend a mandatory orientation meeting. Mark your calendar now! All practice and training sessions will occur at the Franklin Division of Fire & EMS, 45 East 4 th Street, Franklin Ohio 45005. 7 p.m. on April 16, 2018 OR 8 a.m. on April 17, 2018 It is not necessary to notify us which meeting you wish to attend. A photo ID will be required. Please be on time, as late arrivals will not be admitted. This meeting will provide you with an overview of the Candidate Physical Abilities Test (CPAT) and will serve as the first informal CPAT (non-timed). You will be shown a video demonstrating the CPAT program and will receive a candidate preparation guide to assist you. If you possess a valid CPAT certificate issued no earlier than July 18, 2017 from a licensed CPAT provider, that certificate will be accepted in lieu of completing this CPAT exam. The candidate will advance to the written examination round. CPAT certificates will NOT be accepted after April 17, 2018. Several administrative items will also be reviewed at the introductory meeting. Although it is highly discouraged, you will be given the opportunity to waive some portions of future CPAT practice offerings. Additional dates of significance to be aware of include: *Starting Time 6 PM April 25, 2018* 2 nd Informal CPAT Practice May 25, 2018* 1 st Timed CPAT Practice June 27, 2018* 2 nd Timed CPAT Practice July 18, 2018** FINAL CPAT TEST **As shown above, the FINAL CPAT TEST, conducted by the Franklin Civil Service Commission offered on Wednesday, July 18, 2018. Your time slot will be provided at a later date. Candidates successfully completing CPAT will be administered a written examination Saturday July 21, 2018 beginning at 9:30 a.m. The written examination will be held at the Franklin Public Library located at 44 E. 4 th Street, Franklin Ohio 45005 (directly across the street from the fire station). Applicants successfully completing the written examination will be placed on the eligibility list in accordance with their scores, to establish a current full-time Firefighter/EMT AND Firefighter/Paramedic eligibility list for the City of Franklin. Additional information concerning the Written Examination will be provided at the orientation meeting. We do anticipate hiring candidates from this list. 1 FIREFIGHTER EMT PARAMEDIC EXAM INFO 3-2018
Eligibility Requirements: Age Requirements: Must be between the ages of 18 and 40 at the time of appointment. Physical Examination: Must meet physical requirements for Firefighter/Paramedic as stipulated by the Ohio Police and Fire Pension Board. Required Certifications: Applicant must possess a certificate under ORC 4765.55 evidencing satisfactory completion of a firefighter training program and a valid certificate issued under ORC 4765.30 to practice as and EMT-basic or an EMT- Paramedic. Preference in hiring will be given to those persons who are certified as paramedics. Must have valid Ohio Driver s license. APPLICATION FEES: There is an application fee of $25. This payment must be made upon submitting the completed application to the city. Individuals requiring CPAT testing (we will accept CPAT Certificates from approved testing sites within 1 year of issue- see above) must also pay an additional $50 testing fee at the orientation meeting. Forms of payment: You can pay by cash, check or money order. Your check or money order should be made out to the City of Franklin. No credit or debit cards accepted. Applications, job descriptions and full testing details are available at the Franklin City Building, 1 Benjamin Franklin Way, Franklin, Ohio or the city website www.franklinohio.org. ALL COMPLETED APPLICATIONS, FEES AND FORMS MUST BE RECEIVED AT THE CITY BUILDING ON OR BEFORE FRIDAY, APRIL 13, 2018 AT 4 PM. Present starting salary for EMT Basic is $13.53 an hour ($37,288 Base) and EMT Paramedic starts at $15.61 an hour ($43,021 Base). In addition to other benefits, the city picks-up 10% of the employee s pension costs. A photo identification must be shown on each day of testing. NO PHONE CALLS PLEASE EOE 2 FIREFIGHTER EMT PARAMEDIC EXAM INFO 3-2018
APPLICATION FOR EMPLOYMENT CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER Instructions: Please complete this form completely and accurately. Please use a pen and print clearly. SECTION I PERSONAL INFORMATION Name: Last First MI Street Address City State Zip Code Home Phone or Cell Phone Work Phone E-mail Address May we contact you at: Home Best times: Work Best times: Birthdate: / / SSN: - - Are you an American citizen? Yes No If no, are you aware of any problems with your Visa or Immigration Status that would prevent you from lawfully being employed? Yes No If yes, please explain: * Proof of citizenship or immigration status will be required upon employment. SECTION II APPLICATION Position(s) you are applying for: Are you applying in response to an advertisement? Yes No If yes, where did you see the job advertised: Are you seeking: Full-time Part-time Seasonal Volunteer No Preference Are you currently on lay-off status and subject to recall? Yes No If yes, where: Minimum salary expectation: $ Date available to start: / / Form A 1
APPLICATION FOR EMPLOYMENT SECTION III EMPLOYMENT HISTORY Please list your last five employers, beginning with the most recent: CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER Dates Employed: Your Job Title: Employer s Name Beginning: From: Month/Year End: Street Address/City/State/Zip Your Salary: To: Supervisor s Name Month/Year Beginning: End: Describe your duties, responsibilities, equipment operated, etc.: Describe your reason(s) for leaving: Dates Employed: Your Job Title: Employer s Name Beginning: From: Month/Year End: Street Address/City/State/Zip Your Salary: To: Supervisor s Name Month/Year Beginning: End: Describe your duties, responsibilities, equipment operated, etc.: Describe your reason(s) for leaving: Form A 2
APPLICATION FOR EMPLOYMENT CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER Dates Employed: Your Job Title: Employer s Name Beginning: From: Month/Year End: Street Address/City/State/Zip Your Salary: To: Supervisor s Name Month/Year Beginning: End: Describe your duties, responsibilities, equipment operated, etc.: Describe your reason(s) for leaving: Dates Employed: Your Job Title: Employer s Name Beginning: From: Month/Year End: Street Address/City/State/Zip Your Salary: To: Supervisor s Name Month/Year Beginning: End: Describe your duties, responsibilities, equipment operated, etc.: Describe your reason(s) for leaving: Form A 3
APPLICATION FOR EMPLOYMENT CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER Dates Employed: Your Job Title: Employer s Name Beginning: From: Month/Year End: Street Address/City/State/Zip Your Salary: To: Supervisor s Name Month/Year Beginning: End: Describe your duties, responsibilities, equipment operated, etc.: Describe your reason(s) for leaving: SECTION IV EDUCATION AND TRAINING School Name and Location Formal Education College Technical School Years Completed 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 Above 1 2 3 4 Above Diploma/Degree/Major Other School(s) attended: Please describe the courses, technical training or skills you have attained which you feel would help you perform the job for which you are applying (e.g. special machines or equipment you operate, hobbies or volunteer work projects which have taught you qualifying skills, etc): Form A 4
APPLICATION FOR EMPLOYMENT CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER SECTION V - REFERENCES Provide the names and phone numbers of five references (not related to you) who would know of your skills for this position: Name: Is this a business or personal reference? Business Personal Name: Is this a business or personal reference? Business Personal Name: Is this a business or personal reference? Business Personal Name: Is this a business or personal reference? Business Personal Name: Is this a business or personal reference? Business Personal Phone: Phone: Phone: Phone: Phone: SECTION VI MISCELLANEOUS (The following information will be used only if it is directly related to the classification/position for which you are applying.) Have you previously been employed in Ohio by the State, a county, a city, a village, a township or any other governmental entity? Yes No If yes, where and what was your job title: Have you any job-related training in the U.S. Military? Yes No If yes, what kind of training? Have you ever filed an application here before? Yes No Have you ever been employed here before? Yes No Form A 5
APPLICATION FOR EMPLOYMENT CITY OF FRANKLIN, OHIO AN EQUAL OPPORTUNITY EMPLOYER SECTION VII SIGNATURE PAGE I hereby declare that the information provided by me in this application for employment is true, correct and complete to the best of my knowledge. I understand that, if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I hereby authorize the City to perform all necessary job-related evaluations to determine my qualifications for the position, including to obtain information through contacts with my former employers and references, through interviews and through a background check. I understand that if I have applied for a classified position through a Civil Service Examination, such job-related evaluations will not be conducted unless I am on the eligibility list for the tested position. I hereby acknowledge that I am aware that if I am made a conditional offer of employment, I may also be required to pass appropriate examinations as a condition to employment to determine whether I am able to perform the essential functions of the job, with reasonable accommodation where necessary. Such examinations may include a physical exam, drug test, voice stress test, or other appropriate examination. Date: Applicant s Signature Form A 6
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 1 of 7 Department: Safety Title: Firefighter Division: Fire & EMS Civil Service Status: Classified Reports to: Chief; Assistant Chief; Captains; Employment Status: Full-Time Lieutenants FLSA Status: Non-Exempt Supervises: Second Lieutenants; Volunteer Firefighters QUALIFICATIONS: A full-time/career firefighter must meet the following qualifications as a condition of employment, including continued employment: 1. Verified as eligible for employment by the Department of Homeland Security, U.S. Citizenship and Immigration Services. 2. High school diploma or equivalent. 3. Must reside within Warren County or a contiguous county within six (6) months after permanent employment and must continue to reside within such limitations as a condition of employment. 4. Is at least eighteen (18) years of age but not more than forty-one (41) years of age. 5. Has, not more than one hundred twenty (120) days prior to the date of appointment, passed a physical examination, given by a licensed physician, a physician s assistant, a clinical nurse-specialist, a certified nurse-practitioner, or a certified nurse-midwife, certifying that the applicant is free of cardiovascular and pulmonary diseases, and showing that the appointee meets the physical requirements necessary to perform the duties of a firefighter, as established by the City. 6. Has passed a criminal records check. 7. For employees hired from outside the City s service, submit to and successfully complete any of the following requested tests: A. A physical examination (including an eye test), which must show the person is free of cardiovascular and pulmonary diseases and that the person meets the physical requirements necessary to perform the duties of a firefighter. B. A polygraph or voice stress analysis test. C. A written examination and/or agility test. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 2 of 7 LICENSURE AND/OR CERTIFICATION REQUIREMENTS: certifications must be maintained as a condition of continued employment: The following license and 1. A Valid Ohio driver s license, with a driving record that will allow the person to be covered under the City s insurance. 2. State Firefighter Level II (Career) Certification. 3. State-certified to practice as an EMT-basic.* 4. State-certified to practice as an EMT-paramedic.* 5. State Fire Inspector Certification (within one (1) year from date of hire). * Highest level of certification obtained or held during employment must be maintained as a condition of continued employment. MINIMUM ACCEPTABLE CHARACTERISTICS: 1. Firefighting: A. Knowledge of: Incident command principles and procedures; Geographic layout of jurisdiction; Fire suppression and prevention techniques; Fire and emergency rescue techniques; fire investigation and arson detection techniques; Fire Code; Thorough knowledge of the utilization, operation, and maintenance of all apparatus, tools and equipment used in firefighting operations; Thorough knowledge of methods used in combating, extinguishing and preventing fires and in rescue work; Safety practices and procedures; Division goals and objectives; and Division policies and procedures; Building Construction and related codes, electric codes, hydraulics and the location of hazardous occupancies in the City; Water systems and water mains; and public relations. B. Skill in: Computer operation; Use and operation of firefighting and rescue equipment, including motor vehicles; Use of technology and mechanical aptitude. C. Ability to: To apply firefighting, fire prevention, fire protection, and rescue techniques and methods to specific situations; Act quickly, calmly, and effectively during emergencies and remain calm under duress and strain; Understand and follow oral and written instructions; Understand the need for and to function well in an atmosphere of discipline and teamwork; Exercise independence of judgment and action in circumstances of extreme urgency where referral to a supervisor for instruction is not possible; Perform physically arduous work requiring strength and agility during training and in the performance of assigned duties for extended periods of time in often adverse conditions; Learn to drive firefighting vehicles and operate firefighting apparatus; Communicate effectively, both orally and in writing; Develop and maintain effective working relationships; and Interest and willingness to assist in community efforts throughout the City. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 3 of 7 2. Emergency Medical Services: A. Knowledge of: Incident command principles and procedures; Geographic layout of jurisdiction; Emergency medical procedures; Symptoms of medical emergencies and of appropriate responses to such conditions; Proper utilization and maintenance of Division tools and equipment used in emergency medical services operations; Safety practices and procedures; Division goals and objectives; and Division policies and procedures. B. Skill in: Computer operation, Use and operation of emergency medical equipment and tools, including motor vehicles; Technological aptitude. C. Ability to: Independently evaluate/assess patients conditions and properly treat or render emergency medical care; To operate emergency vehicles; To respond quickly and effectively to emergency situations under stressful conditions in the presence of contagious disease and environmental, chemical, or physical violence hazards; To interact with patients, their families, and other medical personnel; Communicate effectively, orally and in writing; Follow established protocols; To document findings and events for the patient s medical record; Understand and follow oral and written instructions; Understand the need for and to function well in an atmosphere of discipline and teamwork; Exercise independence of judgment and action in circumstances of extreme urgency where referral to a supervisor for instruction is not possible; and To develop and maintain effective working relationships. ESSENTIAL FUNCTIONS OF THE POSITION: For the purposes of 42 USC 12101. 1. Firefighting: A. Responds to fire alarms and participates in fire suppression activities and rescue operations; Performs all normal duties of a firefighter (e.g. responds to fire and rescue alarms and assists with controlling and extinguishing fires; lays and connects hose, holds nozzles and directs water streams; raises and climbs ladders; uses chemical extinguishers, bars, hooks, lines, pumps, generators and other equipment; utilizes axes, ropes, bolt cutters, power tools and related firefighting equipment to assist in firefighting operations; performs rescue and salvage operations, etc.). B. Drives and operates motor-driven firefighting equipment and vehicles. C. Carries out daily shift operations and assignments, as directed by supervisory staff or Commanding Officer. D. Supervises volunteer fire personnel assigned to shift; Supervises daily operations and emergency operational scenes as directed by Incident Command and superior officers. E. Functions as Incident Commander in absence of, or until relieved by, a superior officer; Directs volunteer firefighters responding to emergency calls. F. Responds to fire emergency and non-emergency calls for service while on duty; Assures identified roles and responsibilities for type of service are quickly and efficiently handled in accordance with identified Division policies and procedures. G. When assigned to fire prevention, performs inspections of residential, commercial and industrial properties for fire hazards and to enforce the City s Fire Code, and performs related clerical duties as required. H. Instructs shift training and drills as directed by Training Captain or by the Fire & EMS Chief. I. Performs public education activities, as requested and directed by the Fire & EMS Chief, Captain and/or the shift commander. J. Performs daily apparatus inspections and readiness of all equipment, and reports any deficiencies to appropriate shift commander or to the Fire & EMS Chief for repair; Performs various maintenance tasks on apparatus and equipment. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 4 of 7 K. Maintains records and prepares reports regarding alarms, daily activities, supplies and other matters relating to the Fire & EMS Division; Receives and records non-emergency calls received by telephone and assists in dispatching the proper apparatus and equipment to respond to non-emergency call. L. Meets all job safety requirements and all applicable OSHA safety standards and NFPA regulations that pertain to essential functions. M. Demonstrates regular and predictable attendance; Subject to on-call twenty-four (24) hours a day, seven (7) days a week with additional call back status, as directed by the Fire & EMS Chief or Shift Commander. N. Attends various meetings, seminars and workshops to stay abreast of changes in firefighting practices and procedures. O. Maintains requirements set out pursuant to the Fitness for Duty clause set forth in the agreement between the City of Franklin and the IAFF Local 3742. P. Performs related duties as required. 2. Firefighter - EMT: A. Performs necessary basic life support on sick, injured or convalescent persons at the sites of emergencies or in route to hospitals or other medical facilities. Patient care may include hemorrhage control and treatment for shock, manual or automated external defibrillation, cardiopulmonary resuscitation, airway maintenance, and/or fracture stabilization. B. Records event information including patient condition, patient history, treatments, vital signs, and scene observations; Maintains a daily log of responses. C. Relays patient information to physicians and/or hospital via radio transmission, computer, and/or direct contact. D. Operates emergency medical vehicles in route to emergencies and during patient transport to hospital or other medical facility. E. Performs inspections and readiness of all equipment and tools, maintains inventories of supplies, and reports any deficiencies to appropriate shift commander or to the Fire & EMS Chief. F. Observes established basic medical protocols and acts within the scope of practice for the EMT-certification level as set forth by the State of Ohio. G. Observes the Greater Miami Valley EMS Council protocol and passes the yearly protocol test for EMTs. H. Meets all standards prescribed by the City s Medical Director for the provision of emergency medical services. Failure to do so may result in a recommendation by the Medical Director to the Fire & EMS Chief for the Volunteer to be suspended from providing emergency medical services. I. Meets all job safety requirements and all applicable OSHA safety standards and NFPA regulations that pertain to essential functions. J. Attends various meetings, seminars and workshops to stay abreast of changes in emergency medical services practices and procedures. K. Carries out daily shift operations and assignments, as directed by supervisory staff or Commanding Officer. L. As assigned, performs public education activities, as requested and directed by the Fire & EMS Chief, and/or the Shift Commander. M. Performs related duties as required. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 5 of 7 3. Firefighter - Paramedic: A. Performs necessary basic and advanced life support on sick, injured or convalescent persons at the sites of emergencies or in route to hospitals or other medical facilities. Patient care may include hemorrhage control and treatment for shock, intravenous therapy, medication administration, electrocardiogram interpretation; manual or automated external defibrillation or synchronized cardioversion, cardiopulmonary resuscitation, airway maintenance via endotracheal intubation or cricothyroidotomy, fracture stabilization, and/or pain control. B. Records event information including patient condition, patient history, treatments, vital signs, and scene observations; Maintains a daily log of responses. C. Relays patient information to physicians and/or hospital via radio transmission, computer, and/or direct contact. D. Operates emergency medical vehicles in route to emergencies and during patient transport to hospital or other medical facility. E. Performs inspections and readiness of all equipment and tools, maintains inventories of supplies, and reports any deficiencies to appropriate shift commander or to the Fire & EMS Chief. F. Observes established basic and advanced medical protocols and acts within the scope of practice for the Paramedic-certification level as set forth by the State of Ohio. G. Observes the Greater Miami Valley EMS Council protocol and passes the yearly protocol test for Paramedics. H. Meets all standards prescribed by the City s Medical Director for the provision of emergency medical services. Failure to do so may result in a recommendation by the Medical Director to the Fire & EMS Chief for the Volunteer to be suspended from providing emergency medical services. I. Meets all job safety requirements and all applicable OSHA safety standards and NFPA regulations that pertain to essential functions. J. Instructs shift training and drills as directed by Training Captain or by the Fire & EMS Chief. K. Attends various meetings, seminars and workshops to stay abreast of changes in emergency medical services practices and procedures. L. Carries out daily shift operations and assignments, as directed by supervisory staff or Commanding Officer. M. As assigned, performs public education activities, as requested and directed by the Fire & EMS Chief, and/or the shift commander. N. Performs related duties as required. EQUIPMENT OPERATED: The following are examples only and are intended to be all inclusive. Computers and other electronic equipment; Emergency medical services vehicles, tools and equipment; Fire/Rescue apparatus of all types, including boats, vehicles, various tools and associated equipment; Office equipment and machines; Two-way radios. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 6 of 7 INHERENTLY HAZARDOUS OR PHYSICALLY DEMANDING WORKING CONDITIONS: The physical demands described here are representative of those that must be done by the employee to successfully perform the essential functions of the job and shall not be considered all-inclusive. While performing the duties of the job, the employee is frequently required to sit; use hands to touch, handle, hold or feel telephones, keyboards, tools, controls, equipment and other objects and to reach with hands and/or arms; and talk and hear. The employee is frequently required to stand, walk, climb or balance, and must occasionally stoop, kneel, crouch and lift or move up to fifty pounds (50 lbs.) or more. The employee will be exposed to extreme temperatures, human blood or other bodily substances, contagious diseases, infectious agents, physical and emotional stress, physically-demanding work, and environmental, chemical or physical violence hazards. The employee may have to operate in environments of high noise, poor visibility, limited mobility, at heights and in enclosed or confined spaces. The employee must be able to withstand extreme temperatures and endure physical stress, to spend extensive time outside and endure exposure to the elements, and to tolerate extreme fluctuations in temperatures while performing duties; and to work in areas where sustaining traumatic or thermal injuries is possible. Mental alertness is very important because of the need to make fine discriminations and decisions concerning subtle clues of impending danger. GENERAL DUTY: SAFE AND HEALTHFUL WORKPLACE: The employee: 1. Uses or works in proximity to the use of firearms. 2. Works in or around crowds. 3. Has contact with potentially violent, assaultive, or emotionally distraught or dangerous persons, which may require physical contact with such persons. 4. Has exposure to potentially vicious animals. 5. Has exposure to life-threatening situations. 6. Has exposure to fire. 7. Has exposure to hot, cold, wet, humid or windy weather conditions. 8. Has exposure to hazardous driving conditions. 9. May have to work 2 nd shift or 3 rd shift. 10. May have to sit or stand for extended periods of time. 11. Has exposure to second-hand smoke. 12. May be required to lift, push, pull or carry heavy loads. Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)
CITY OF FRANKLIN An Equal Opportunity Employer POSITION DESCRIPTION Firefighter Page 7 of 7 13. Has exposure to contagious diseases, infectious agents, blood or other bodily substances. 14. Has exposure to hot (up to 400 F), humid (up to 100%) atmospheres while wearing equipment that significantly impairs body cooling mechanisms, and will be exposed to frequent, extreme fluctuations in temperatures and atmospheres. 15. Has exposure to carcinogenic dusts, such as asbestos, or toxic substances, such as hydrogen cyanide, acids, carbon monoxide or organic solvents either through inhalation or skin contact. 16. Has exposure to wet, icy or muddy areas and slippery, hazardous surfaces, such as ladders and rooftops. **Check boxes applicable to appointee s position. If numbered item has no check box, it applies to appointee s position.** This position description in no manner states or implies that these are the only duties and responsibilities to be performed by the position incumbent. My (employee) signature below signifies that I have reviewed and understand the contents of my position description. I acknowledge and agree that this position description is a guide, is not contractual in nature, and the duties and responsibilities of the position are subject to change. Further, I acknowledge that I am required to maintain certain licenses and certifications as condition of continued employment, and that certain criminal acts may subject me to discipline, suspension or immediate termination. I hereby grant to the City the authority to perform routine checks on my licenses, certifications and criminal records as a condition of my continued employment. I hereby acknowledge and grant permission for such routine checks, which may include use of my license(s) number (s), certification(s) number(s) or social security number. Name of Employee: Employee Signature Date Approval of Appointing Authority Date Date Adopted: 08/18/03 (Res. 2003-77) Date Revised: 04/05/04 (Res. 2004-23); 11/07/16 (Res. 2016-53)