2. St. Bernard Parish Fire Department Firefighter Application
4. We consider applications 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.
6. (Please Note: All information must be supplied in order for application to be considered.)
10. Date
    Date
12. Last Name
13. First Name
14. MI
15. Date of Birth
    Date of Birth
17. Address
19. City
20. State
21. Zip Code
23. Phone
24. Email Address
28. Have you taken the Firefighter entrance exam?

    1. Yes
    2. No
29. Have you ever been convicted of a felony?

    1. Yes
    2. No
33. Education
35. High School
36. Years Attended
37. Graduation Year
39. College
40. Years Attended
41. Graduation Year
42. Major
44. Trade School
45. Years Attended
46. Graduation Year
47. Area of Focus
51. Employment
    List your last two employers. (Starting with the last/present one first.)
53. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
54. Name/Address of Employer
55. Position?
56. Still employed?

    1. Yes
    2. No
58. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
59. Name/Address of Employer
60. Position?
61. Still employed?

    1. Yes
    2. No
65. References
    Give the names of three (3) persons, not related to you, whom you've known for at least a year.
67. Name
68. Number
69. Business Association
70. Years Aquainted?
72. Name
73. Number
74. Business Association
75. Years Aquainted?
77. Name
78. Number
79. Business Association
80. Years Aquainted?
84. List any additional skill and/or training:
88. Acknowledgment*

    By submitting this form, I understand that I am submitting to a background check by St. Bernard Parish Government.

    1. I agree
90. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
92. Signature of Applicant*
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field