Cal Fire 215 Form – Fill Out and Use This PDF

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)

FIRE FIGHTER I	PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICATION FOR EMPLOYMENT
CAL FIRE 215 (REV. 3/13) Page 1

ANSWER THE FOLLOWING QUESTIONS:

1.	Do you need reasonable accommodation to take an oral interview?	YES	NO
2.	Do your religious beliefs prevent you from taking an interview on Saturday?	YES	NO
3.	Do you meet the minimum age requirements of 18 years?	YES	NO
	If you are not 18, please provide your date of birth: _____________________________

4.Have you ever: (If “YES”, give details in Item 5 below and refer to the Instructions for further details.)

a.	Been dismissed or fired from a position for any reason?	YES	NO

b.	Resigned from or quit a position while under investigation or after being informed
	discipline would be taken against you, or during an appeal from a disciplinary action?	YES	NO

c.Been rejected or told you would not receive permanent or continued employment during

any type of probationary or trial period on the job?

YES

NO

5.EXPLANATIONS

I.EDUCATION: Please fill in the box that corresponds to the HIGHEST LEVEL of education completed, major (if applicable), and completion date. Please note that copies of transcripts and/or diploma MAY BE REQUIRED prior to appointment.

Personnel Use Only: [MAX] 10 _________________

II.TRAINING: Please indicate which certification courses and/or emergency medical training you have successfully completed by marking ―yes‖ or ―no‖ for each course. Copies of current certifications WILL BE REQUIRED prior to appointment.

Personnel Use Only: [MAX] 45 _________________

CERTIFICATION—IMPORTANT⎯PLEASE READ BEFORE SIGNING—If not signed, this application may be rejected.

I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge. I further understand any false, incomplete, or incorrect statements may result in my disqualification from the selection process or dismissal from employment with the State of California. I authorize the employers and educational institutions identified on this application to release any information they may have concerning my employment or education to the State of California. Resumes will not be accepted in lieu of a completed application.

APPLICANTS—DO NOT USE THIS SPACE BELOW—FOR OFFICIAL USE ONLY

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)

FIRE FIGHTER I	PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICATION FOR EMPLOYMENT
CAL FIRE 215 (REV. 3/13) Page 2

III.FIREFIGHTING EXPERIENCE: List the applicable information specified below including classification title, location, employer, and

	months of experience. ALL INFORMATION WILL BE VERIFIED PRIOR TO APPOINTMENT.	[MAX] 30 _________________

A). CDF FIREFIGHTING EXPERIENCE

Include CDF firefighting experience only (i.e., Fire Fighter I, Conservation Camp, Fire Center)

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	CDF UNIT
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING
FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	CDF UNIT
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

B.) FULL-TIME NON-CDF FIREFIGHTING EXPERIENCE

Include full-time firefighting experience with other organizations (i.e., City, County, USFS, BLM, or National Park Service, etc.)

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)

FIRE FIGHTER I	PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICATION FOR EMPLOYMENT
CAL FIRE 215 (REV. 3/13) Page 3

III. FIREFIGHTING EXPERIENCE, CONTINUED:

B.) FULL-TIME NON-CDF FIREFIGHTING EXPERIENCE

Include full-time firefighting experience with other organizations (i.e., City, County, USFS, BLM, or National Park Service, etc.)

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

C.) PAID CALL, VOLUNTEER AND/OR RESERVE FIREFIGHTING EXPERIENCE

Include firefighting experience gained as a Paid Call, Volunteer, and or Reserve Fire Fighter and/or CDF Emergency Worker or Fire Fighter Explorer

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED	ADDRESS	COMPANY/STATE AGENCY NAME
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)

FIRE FIGHTER I	PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICATION FOR EMPLOYMENT
CAL FIRE 215 (REV. 3/13) Page 4

IV. NON-FIREFIGHTING EXPERIENCE: List the applicable information specified below including classification title, location, employer, and

	months of experience. ALL INFORMATION WILL BE VERIFIED PRIOR TO APPOINTMENT.	[MAX] 15 _________________

A.) PUBLIC SAFETY

Include work experience in a public safety area of AT LEAST 6 MONTHS DURATION (i.e., CDF Volunteers in Prevention, Military, Security Guard, Lifeguard, Dispatcher, Park Ranger)

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

B.) MEDICAL CARE PROVIDER

Include work experience as a medical care provider of AT LEAST 6 MONTHS DURATION. Experience must include direct patient care (i.e., Ambulance Attendant, Emergency Room Technician). Do NOT include non-medical experience.

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CAL FIRE)

FIRE FIGHTER I	PRINT OR TYPE - PLEASE SEE INSTRUCTIONS ON BACK PAGE
APPLICATION FOR EMPLOYMENT
CAL FIRE 215 (REV. 3/13) Page 5

IV. NON-FIREFIGHTING EXPERIENCE, CONT.:

C.) TRADES/INDUSTRIAL/OTHER EXPERIENCE

Include trades/industrial experience of AT LEAST 6 MONTHS DURATION (i.e., Carpenter, Mechanic, Cook, etc.).

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING
FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

FROM (MDY)	TO (MDY)	JOB TITLE/CLASSIFICATION (Include Range or Level, If applicable)
HOURS PER WEEK	TOTAL WORKED (Years/Months)	COMPANY/STATE AGENCY NAME
SALARY EARNED		ADDRESS
$	PER
DUTIES PERFORMED

REASON FOR LEAVING

NOTE: IF MORE SPACE IS NEEDED FOR EXPERIENCE, ATTACH ADDITIONAL PAGES.

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CDF)

FIRE FIGHTER I

APPLICATION FOR EMPLOYMENT

CDF 215 (REV. 3/13) Page 6

EQUAL EMPLOYMENT OPPORTUNITY

APPLICANT: To assist the State of California in its commitment to Equal Employment Opportunity, applicants are asked to voluntarily provide the following information. This questionnaire will be separated from the application prior to any employment decisions. Government Code Section 19705 authorizes the State Personnel Board to retain this information for research and statistical purposes.

Ethnic Category (Please check the box that best describes your race/ethnicity):

AMERICAN INDIAN OR ALASKAN NATIVE - Persons having origins in any of the tribal peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

ENTER TRIBAL IDENTIFICATION OR AFFILIATION:

ASIAN - Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This includes China, Japan, and Korea.

BLACK - Persons having origins in any of the black racial groups of Africa.

FILIPINO - Persons having origins in any of the original peoples of the Philippine Islands.

HISPANIC - Persons of Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.

PACIFIC ISLANDERS - Persons having origins in the Pacific Islands, such as Samoa.

WHITE - Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Check if:

OTHER (Specify)

DISABLED - A person with a disability is an individual who:

(1)Has a physical or mental impairment that substantially limits one or more life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or working;

(2)Has a record of such an impairment;

(3)Is regarded as having such impairment.

MILITARY - A military veteran; a widow or widower of a veteran; or a spouse of a 100% disabled veteran.

OTHER (Specify) ___________________________

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION (CDF)

FIRE FIGHTER I

APPLICATION FOR EMPLOYMENT

CDF 215 (REV. 12-01) Page 7

INSTRUCTIONS

Read the following instructions carefully before completing this Application. Please complete the Application on a typewriter or personal computer or print in ink. All questions must be answered completely and accurately, except as noted. You may be disqualified for any false or misleading statements or for omitting information. The information you furnish will be used to determine your eligibility and/or may be the basis for arriving at your final rating. You may be requested to provide additional information regarding your qualifications, your preference regarding work shifts, etc., and health/medical background.

PLEASE ENTER YOUR NAME ON PAGES 1 THROUGH 5

AND STAPLE ALL PAGES OF THE

APPLICATION TOGETHER BEFORE SUBMITTING!