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The information that you provide in this section will be used ONLY in the event of your serious injury or death. Family or friends you would like the department to contact. Note: If the contact is a minor child, please indicate the name of the adult to contact.
List Addresses for the past five years.
I hereby certify that to the best of my knowledge and belief the answers given by me to the foregoing questions and all statements made by me in the application process are accurate and are subject to verification. I authorize all previous employers and listed references to furnish whatever information they may have regarding my employment and my reason for leaving. I understand that I may be refused membership by giving false or misleading information in my application or interview(s), or in the event of membership to the organization, I may be immediately discharged. I understand that as part of the application process, I am subject to a criminal background investigation and a health physical. I understand that additional personal data will be required to determine if I am eligible for benefits and for statistical/governmental reporting purposes. I also understand that proof of U.S. permanent residency or authorization to work in the U.S. is required upon membership/employment decision and further understand that this application is not intended to be a contract for employment. I understand and acknowledge that membership begins upon my appointment by the Fire Chief, and that I am required to abide by all rules, regulations, bylaws and standard operating policies of the jackson Hole Fire/EMS Department. I understand that I will be on probation for twelve (12) months starting from my appointment date, which includes, but is not limited to, attendance of all meetings, regular maintenance and training meetings as set forth by the department. I understand that eligibility to the Wyoming Retirement System, Transamerica and Firefighter I testing time will all start after the twelve (12) month probationary period.
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.
This field is not part of the form submission.
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