36 BURTON HILL RD. BEAUFORT, SC 29906

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1 HARRY G. ROUNTREE FIRE CHIEF WORK: (843) FAX: (843) BURTON HILL RD. BEAUFORT, SC Dear Applicant, Thank you for seeking an employment opportunity with the Burton Fire District. You will find us to be a progressive department that prides itself on fire suppression and prevention, public education and training. The District currently employs forty-nine shift personnel and eight staff personnel. We serve and protect approximately eightythree square miles with five stations. The District responds to approximately 3000 emergencies each year with nearly half of those being medical emergencies. You can find out more information about the Burton Fire District by visiting us on the web at If you have any questions please don t hesitate to ask. Harry Rountree Fire Chief

2 Application For Employment (PLEASE PRINT) Burton Fire District 36 Burton Hill Rd. Beaufort, SC We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. When completing this application, you should be aware that the Burton Fire District is a drug free workplace. If you are accepted for employment, you will be required to submit to drug/alcohol screening during your pre-employment process. Should you test positive, your application will be rejected. Once employed safety sensitive positions will be subjected to annual random drug/alcohol screening. Be aware that the Burton Fire District requires all applicants to submit a driving record from the State Department of Motor Vehicles for the past 5 (five) years. Please attach this to the back of your application. Position(s) Applied For: Date of Application: / / How Did You Learn About Us? Advertisement Friend Walk-In Employment Agency Relative Other: Last Name First Name Middle Initial Address Number Street City State Zip Code Telephone Number(s) ( ) - - Driver s License # and Issuing State Social Security Number - - Have you ever filed an application with us before? Yes No Have you ever been employed with us before? Yes No Are you currently employed? Yes No May we contact your present employer? Yes No Are you prevented from lawfully becoming employed Yes No in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment. On what date would you be available for work? / / Are you currently on lay-off status and subject to recall? Have you been convicted of a felony within the last 7 years? Yes Yes No No Conviction will not necessarily disqualify an applicant from employment. If yes, please explain

3 Education School Name and Location Elementary School High School Undergraduate Graduate/ College/ University Professional Years Completed Diploma/ Degree Describe Course of Study Describe any specialized training, apprenticeship, skills, and extra curricular activities De scribe any honors you have received State any additional inf ormation you feel may be helpful to us in considering your application Speak Read Write Indicate any foreign languages you can speak, read, and/ or write Fluent Good Fair List Professional, Trade, Buisness, or Civic activities and offices held. References Give name, address, and telephone numb er of three references that are not related to you and are not previous employers Have you ever had any job- related training in the Yes No United States Military? If Yes, please describe:

4 Employment Experience Start with your present or last job. Include any job- related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, handicap or other protected status. 1 1 Leaving: Reason for Leaving: 2 Reason for Leaving: 3 Reason for Leaving: 4 Reason for Leaving: If you need additional space, please continue on a separate sheet of paper. Special Skills and Qualifications Summarize special job- related skills and qualifications acquired from employment or other experience.

5 Applicant s Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize investi gation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. Signature of Applicant: Date: FOR DEPARTMENT USE ONLY Arrange Interview: Yes No Remarks: Employed Yes No Date of Employment: Job Ti tle: : Department: By: Name and Title Date Notes:

6 Applicant Data Record PLEASE PRINT Qualified applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. help us comply with government record keeping, reporting and other legal requirements, please fill out the Data Record. This Data is for periodic government reporting and will be kept in a Confidential File. Position(s) Applied For: Date of Application: / / How Did You Learn About Us? Advertisement Friend Walk-In Employment Agency Relative Other: Information Survey Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affi rmative action only. Sub mission of information about a handicap is voluntary. Check one: Male Female Check one of the following: Race/Ethnic White Black American Indian/Alaskan Native Hispanic Asian/Pacific Islander Check if any of the following are applicable: Vietnam Era Veteran Disabled Veteran Handicapped Individual