CITY OF NEW HAVEN
Department Of Fire Service
Office of the Chief
John DeStefano, Jr. MayorMichael E. Grant, Chief Website www.cityofnewhaven.com 952 Grand Avenue P.O. Box 374 (203) 946-6222 (203) 946-6221/Fax
FIREFIGHTER RECRUITMENT – 2013
APPLICATION PACKET
TABLE OF CONTENTS
The contents of this Application Packet are contained in the following order:
Letter from the Fire Chief
Firefighter Job Announcement
Firefighter Job Description
Requirements for Application
Instructions for Submitting Application & Directions to Application
Submission Site
Information on the Civil Service Exam Process
Description of Examination Process
Application Checklist
Reminder Message from the New Haven Department of Fire Service
Forms Section
-
Application Fee/Waiver Form
-
Waiver Eligibility Guidelines
-
Affidavit Regarding Age, High School Completion & Driver’s License
-
Residency Preference Points Form
-
Preference Points Statement Sheet
-
Gateway Community College Entry-Level Firefighter Test Orientation
CITY OF NEW HAVEN
Department Of Fire Service
Office of the Chief
John DeStefano, Jr. MayorMichael E. Grant, Chief Website www.cityofnewhaven.com 952 Grand Avenue P.O. Box 374 (203) 946-6222 (203) 946-6221/Fax Dear Applicant:
Congratulations! By completing all the necessary forms contained in this special application packet, you are taking the first step toward becoming a member of the New Haven Department of Fire Service. To reach the goal of becoming a firefighter, applicants must successfully complete a number of steps and all the information needed to complete those steps is contained in this packet. The mission of the New Haven Fire Department is to contribute within appropriate authority for the maintenance and improvement of the quality of life in the City of New Haven, accomplished through providing fire suppression; fire prevention; emergency medical service and rescue; emergency communications, special services and emergency management as well as effective training for and administration of these activities.
We are seeking committed individuals to assist us in fulfilling our responsibilities to the citizens of New Haven, and we hope you will join us. On behalf of the City New Haven, I extend my best wishes to you as you begin this endeavor. Your hard work and perseverance will be richly rewarded should you be selected to serve the public as a member of the New Haven Fire Department.
Very truly yours,
Michael E. Grant Chief of the Department
CITY OF NEW HAVEN
DEPARTMENT OF HUMAN RESOURCES
200 ORANGE STREET, NEW HAVEN, CT 06510
www.cityofnewhaven.com
POSTED: March 11, 2013 REMOVAL DATE: March 22, 2013 POSITION: FIREFIGHTER (M-702) (TESTED)
DEPARTMENT: FIRE SERVICE SALARY: $36,491 ANNUALIZED HOURS: 42 HOURS PER WEEK FUNDING: GENERAL FUNDS
This position is subject to a NON-REFUNDABLE $50.00 Application Fee
1(cash, exact amount only, or money
order only) made payable to “TREASURER, CITY OF NEW HAVEN.” Candidates who continue through the Testing
Process to the Oral Examination phase will be subject to an additional NON-REFUNDABLE Testing Fee.
TO APPLY: Follow all instructions provided in this Application Packet to complete and submit your application.
You may submit your completed application starting Monday March 11, 2013. Completed applications will not be accepted before this date. Note: Important instructions detailing where and how to submit your completed application are contained in a later section of this packet.
Completed applications and $50.00 application fee (or fee waiver) MUST be submitted to AS INSTRUCTED IN THIS APPLICATION PACKET and MUST be received no later than Friday, March 22, 2013 by 5 p.m.
COMPLETED APPLICATIONS ACCEPTED ONLY AS INSTRUCTED IN THIS APPLICATION PACKET
NATURE OF WORK:
This is skilled firefighting work in combating, extinguishing, and preventing fires; in rendering medical assistance at medical and other emergency scenes; and in operating and maintaining Fire Department equipment, apparatus and quarters. Work involves responsibility for the protection of life and property through performing firefighting, rescue Emergency Medical Service (EMS) first responder, and related duties. Work is performed as a team; including training and participation in the use of firefighting and emergency medical apparatus, performance of which may be hazardous under emergency conditions. Work may require strenuous exertion under such environments as smoke, fire, heat, confined spaces, and infectious disease. When not engaged in firefighting, rescue or first responder activities, a significant portion of time is devoted to drill and studying methods and techniques, inspecting premises for fire hazards, routine duties in the care of station and equipment maintenance, and other departmental duties as assigned.
MINIMUM REQUIREMENTS TO APPLY:
A t t i m e o f A p p l i c a t i o n m u s t : b e 1 8 y e a r s o f a g e , p o s s e s s a v a l i d d r i v e r ’ s l i c e n s e a n d h a v e g r a d u a t e d f r o m h i g h s c h o o l o r p o s s e s s S t a t e E q u i v a l e n c y D i p l o m a ( G E D ); Ability to learn a wide variety of firefighting duties, evolutions, and methods within a reasonable working test period; Ability to climb ladders and work at considerable heights; Ability to learn locations of streets, principal buildings and other physical features of New Haven; Ability to act quickly and calmly in emergency situations; Ability to follow oral and written instructions; Ability to establish and maintain an effective working relationship with other employees and the public as well as all other Requirements as stated in the job description.
SPECIAL REQUIREMENTS:
Candidates for this classification must be able to meet established educational, physical and medical requirements. Trainees must pass all Fire Academy curriculum and obtain all necessary certifications and/or licenses as required by the Fire Department for graduation from the Academy. Must also have valid State of Connecticut driver’s license at time of conditional offer of employment.
This position is subject to background check, medical and drug testing upon conditional offer of employment.
(M-702) FIREFIGHTER
NATURE OF WORK
This is skilled firefighting work in combating, extinguishing, and preventing fires; in rendering medical assistance at medical and other emergency scenes; and in operating and maintaining Fire Department equipment, apparatus and quarters.
Work involves responsibility for the protection of life and property through performing firefighting, rescue Emergency Medical Service (EMS) first responder, and related duties. Work is performed as a team; including training and participation in the use of firefighting and emergency medical apparatus, performance of which may be hazardous under emergency conditions. Work may require strenuous exertion under such environments as smoke, fire, heat, confined spaces, and infectious disease.
When not engaged in firefighting, rescue or first responder activities, a significant portion of time is devoted to drill and studying methods and techniques, inspecting premises for fire hazards, routine duties in the care of station and equipment maintenance, and other departmental duties as assigned.
Specific orders and assignments are given by a superior officer, in both firefighting and at the fire station, and performed under close supervision in accordance with established policies and procedures. However, performance of the work requires initiative and thorough understanding of firefighting methods and emergency medical care as learned on the job and in training.
ILLUSTRATIVE EXAMPLES OF WORK
Responds to fire alarms with a company; drives apparatus; operates and uses pumps and ladders, uses chemical extinguishers, bar, hooks, lines and other equipment.
Ventilates burning buildings by opening windows and skylights or by cutting openings in roofs and floors; removes persons from danger; administers emergency medical care to ill or injured persons.
Performs salvage operations by placing salvage covers, sweeping water and removing debris.
Performs emergency medical assistance to fire victims and/or as first responders to medical and other emergency situations until arrival of other medically qualified personnel.
Participates in daily training sessions; reads and studies assigned materials regarding firefighting, emergency medical care, fire prevention and related subjects, studies the theory and techniques of firefighting, emergency medical care, hydraulics, fire chemistry, and related subjects; participates in a variety of drills and instructions.
Inspects buildings and premises for familiarization; checks for fire hazards; participates in the inspection and maintenance of fire hydrants, cleaning away snow, ice and grass for accessibility.
Operates fire apparatus and may assume command of a fire company on occasional basis. Participates in pre-planning survey of commercial, industrial and institutional structures.
Performs general maintenance work in the upkeep of Fire Department property; cleans and maintains fire stations and equipment; performs other maintenance duties.
Performs fire prevention and public fire education work. Performs related work as required.
REQUIREMENTS OF WORK
At time of Application must: be 18 years of age, possess a valid driver’s license and have graduated from high school or possess State Equivalency Diploma (GED); and the following knowledge, skills and abilities:
Ability to learn a wide variety of firefighting duties, evolutions, and methods within a reasonable working test period. Ability to climb ladders and work at considerable heights.
Ability to learn locations of streets, principal buildings and other physical features of New Haven. Ability to act quickly and calmly in emergency situations.
Ability to follow oral and written instructions.
Ability to establish and maintain an effective working relationship with other employees and the public. Ability to learn emergency medical care techniques.
Ability to become State certified as an Emergency Medical Technician within two years of employment. Mechanical aptitude and manual dexterity.
Physical strength and agility and the ability to perform arduous tasks under strenuous and adverse conditions. SPECIAL NECESSARY REQUIREMENTS:
Candidates for this classification must be able to meet established educational, physical and medical requirements. Trainees must pass all Fire Academy curriculum and obtain all necessary certifications and/or licenses as required by the Fire Department for graduation from the Academy. Must also obtain appropriate State of Connecticut Department of Motor Vehicle driver’s license as required by nature of assignment.
REQUIREMENTS FOR APPLICATION
Below are steps you must follow to apply for the position of Firefighter in the New Haven Department of Fire Service: 1. Make sure that you meet all minimum requirements per job announcement and job description included in this
Application Packet.
2. Complete a City of New Haven Application for Employment.
3. Attach to your application a completed and signed Affidavit Regarding Age, High School Completion & Driver’s License.
4. Make sure that all documents in this Application Packet that ask for information and your signature are completely filled out and signed.
5. Attach the sheet titled “Application Fee/Waiver Form” located in the Forms Section of this Application Packet. Fill out the appropriate section of the form to indicate whether you are paying or waiving the $50.00 application fee. The Application Fee is NON-REFUNDABLE.
The non-refundable $50.00 application may be waived in cases of financial hardship. Hardship will be considered on a case-by-case basis, and must meet eligibility criteria. Instructions for waiving this fee are included in this Application Packet. Proof of income may be requested.
The $50.00 application fee must be in the form of cash (exact amount only) or money order made payable to “Treasurer, City of New Haven.” No checks, of any kind, accepted. Credit/Debit cards not accepted.
6. New Haven residents wishing to have five (5) extra points added to the final passing score in the examination process must complete the Preference Points Form, provide proof of domicile as instructed on the form, and submit the form with the completed employment application. A total of 3items are required to prove domicile. One must be a picture ID with address. The other two items can be any combination of bills or mail recently received, not more than 60 days old. These must be photocopied and attached to the Preference Points Form. No personal handwritten mail will be accepted.
7. New Haven residents wishing to take the Entry-Level Firefighter Orientation Course offered by Gateway Community College must follow all instructions to sign up for the course and submit those forms together with the completed employment application.
8. War-time veterans who wish to apply for veterans’ points must submit a copy of a DD-214 with the completed
employment application. Disabled war-time veterans must additionally provide proof of disability rating to receive the extra points.
9. CPAT certificate holders with certificates obtained on or after April 1, 2012 can satisfy the Physical Agility testing requirement by submitting a copy of the certificate with the employment application.
10. Complete the sheet titled “Voluntary Survey Form,” located in the Forms Section of this Application Packet, and submit it with your completed employment application. The information requested in this form is voluntary, but extremely helpful to us in evaluating our recruitment efforts.
11. Return your completed application as directed on the page titled “Instructions for Submitting Application.” Make sure to follow all instructions on the sheet.
INSTRUCTIONS FOR SUBMITTING APPLICATION
Completed applications must be submitted BY THE APPLICANT IN PERSON no earlier
than 9:00 AM Monday, March 11, 2013 and no later than 5:00 PM Friday, March 22,
2013 to the Fire Training Academy, New Haven Department of Fire Services. You cannot
mail in your application, and you cannot have someone else drop off your application on
your behalf. You must submit your application in person.
YOU MUST SHOW YOUR CURRENT DRIVER’S LICENSE WHEN SUBMITTING YOUR
APPLICATION.
Human Resources will review your application packet with you to ensure all is in order. Application
packets with incomplete forms, missing information or submitted without the application fee (
unless
applying for a fee waiver
) will be regarded as incomplete and will be rejected.
Remember:
If you are a New Haven resident and are applying for preference points, or you are
applying for the Entry-Level Firefighter Orientation Course, you will be required to provide proof of
domicile at the time you submit your application. (See “Application for Entry-Level Firefighter
Orientation Course” and “Application for Preference Points” included in this packet for more
details).
If you are applying for preference points as a war-time veteran/disabled veteran you must submit a
copy of your DD-214 and rating letter (if disabled).
Please submit your completed application IN PERSON, during hours of operation to:
Fire Training Academy
Department of Fire Service
230 Ella T. Grasso Boulevard
New Haven, CT 06519
See directions to Fire Training Academy
Hours of Operation:
Monday – Friday, 9:00 am – 5:00 pm
Y O U M U S T S H O W Y O U R C U R R E N T D R I V E R ’ S L I C E N S E W H E N S U B M I T T I N G Y O U R A P P L I C A T I O N .
APPLICATIONS RECEIVED AFTER 5:00 PM ON THE DEADLINE DATE OF March 22,
2013 WILL NOT BE ACCEPTED.
DIRECTIONS TO FIRE TRAINING ACADEMY
NEW HAVEN DEPARTMENT OF FIRE SERVICE
230 Ella T. Grasso Boulevard
New Haven, CT 06519
From I-91 South:
From I-91 South: in New Haven follow signs to I-95 South. From I-95 South take Exit 45 (signs
indicate Yale Bowl RT. 10). Go to first traffic light (Ella Grasso Boulevard and Kimberly Avenue)
and continue straight on to Ella Grasso Boulevard. The entrance to the Fire Academy is on the left
just prior to going over the bridge. Building # 1 is the Main Administration facility; please enter
through the front entrance. Parking is available at the end of the cul-de-sac.
From I-95 Traveling Northbound:
From I-95 North: Take Exit 44 (signs indicate Yale Bowl RT. 10). Stay to the right off the exit and
travel onto Kimberly Avenue. At the first traffic light (Ella Grasso Boulevard and Kimberly
Avenue) take a left onto Ella Grasso Boulevard, the entrance to the Fire Academy is on the left just
prior to going over the bridge. Building # 1 is the Main Administration facility; please enter through
the front entrance. Parking is available at the end of the cul-de-sac.
From I-95 Traveling Southbound:
From I-95 south take Exit 45 (signs indicate Yale Bowl RT. 10) go to first traffic light (Ella Grasso
Boulevard and Kimberly Avenue) and continue straight on to Ella Grasso Boulevard. The entrance
to the Fire Academy is on the left just prior to going over the bridge. Building # 1 is the Main
Administration facility; please enter through the front entrance. Parking is available at the end of the
cul-de-sac.
CIVIL SERVICE EXAM PROCESS
The Civil Service testing process for the position of Firefighter includes a physical agility test, a written test and an oral test. Applicants must meet all minimum requirements and submit all applicable fees (or waiver) in order to participate in the Civil Service testing process. There are no make-up dates, and there is no rescheduling for any of these tests.
1. FIRST PHASE OF TESTING - Written Examination – Tentative Date(s) = April 20 & 21, 2013:
Onlyapplicantswho submita completed and acceptedapplication, including the Application Fee or Fee Waiver, andmeet minimum requirements willbe invitedto participate inthefirst phase of testing. Applicants will be notified in writing in advance of the exact test date, time, location and other directions specific to this exam. Once the test date is announced applicants will be required to be present for testing on the date and at the time assigned. There is no make-up date, and there is no rescheduling for this test.
2. SECOND PHASE OF TESTING - Oral Examination – Tentative Date(s) = May 18 & 19, 2013:
Candidates invited to the second phase of testing will be required to submit the additional $30 Non-Refundable Testing Fee at check-in for this exam. Only cash (exact amount only) or money order will be accepted.
Candidates will be notified in writing in advance of the exact test date, time, location and other directions specific to this exam. The Testing Fee may be waived in cases of hardship. Hardship will be considered on a case-by-case basis and must meet eligibility criteria. Instructions for waiving this fee will be included with the Examination Notice.
Once the test date is announced applicants will be required to be present for testing on the date and at the time assigned. There is no make-up date, and there is no rescheduling for this test.
3. FINAL PHASE OF TESTING – Physical Agility Exam – Tentative Date(s) = To be Announced:
Remaining candidates will be notified by mail to attend the final phase of testing. The notice will contain the exact date and location of the exam and scheduling instructions. You will be required to follow all instructions in the notice.
Once the test date is announced applicants will be required to be present for testing on the date and at the time assigned. There is no make-up date, and there is no rescheduling for this test.
IMPORTANT INFORMATION ON THE PHYSICAL AGILITY TEST:
The New Haven Department of Fire Service will accept CPAT Certificates from candidates who obtained their
certificate on or after April 1, 2012. CPAT certificates obtained earlier than this date will not be accepted. If you have a CPAT certificate that meets the date requirement as stated, you must submit a copy of your CPAT certificate with your application. If you acquire a CPAT certificate after the New Haven Firefighter application period closes but before the New Haven physical agility testing dates, you must bring a copy of your CPAT certificate to the agility session to which you are scheduled. For more information about CPAT, go to www.ct.gov/cfpc.
DESCRIPTION OF EXAMINATION PROCESS
Phase 1 -Written Examination
This is a multiple choice test designed to evaluate cognitive ability. Work behaviors and other fundamental
characteristics, such as work ethic and service orientation, are also part of the written examination. The
written examination includes a pass/fail reading comprehension section that you must pass in order to have
your written score count. The written examination score is worth 25% of the total final score in the
examination process. Those who fail the pass/fail portion of the written exam will not advance to the next
phases in testing. For more detailed information on the cognitive portion of the written examination visit:
www.cityofnewhaven.com/HumanResources/FireRecruitment.asp
.
ContactHuman Resources at 203-946-8252 to obtain a print copy.
Phase 2 - Oral Examination
This is a structured test designed to evaluate skills and abilities in problem identification and analysis,
decision making, oral communication, and service orientation in which candidates are asked to respond to
hypothetical situations. Candidates receive all test questions over a video monitor and all candidate responses
will be video taped. The oral examination score is worth 75% of the final score in the examination process.
Phase 3 - Physical Agility Examination
This is a pass/fail process requiring candidates to display physical strength and stamina through a series of
designed exercises conducted at the Fire Academy training grounds. Candidates will be required to complete
the exercise events under established time limits. Details, such as minimum time(s) and description of
exercise events, will be contained in the test notice. For a general idea of what a physical agility examination
of this type entails, visit:
www.cityofnewhaven.com/HumanResources/FireRecruitment.asp
.
Contact Human Resources at 203-946-8252 for alternative methods of access.
Candidates must pass the Physical Agility Exam and achieve a combined score of at least 70.00 or higher
across the Written and Oral Examination phases to be placed on the resulting eligibility list.
APPLICATION CHECKLIST
Use the following checklist to help you in completing your application for submission.
L
isted below are all of the steps required to complete your application. Check each item to ensure that your application is COMPLETE.
Step 1 -- City Of New Haven Employment Application
Did I fill it out completely? (If no, your application is not complete.)
Did I sign and date it across the bottom? (If no, your application is not complete.)
Step 2 – Affidavit Regarding Age, Completion of High School & Driver’s License
Did I attach a signed affidavit attesting that I am 18 years of age and that I possess a high school diploma / GED certificate and driver’s license? (If no, your application is not complete.)
Step 3 -- Payment of
$50.00 Application Fee
Did I check the appropriate box on the Application Fee/Waiver Form and attach it to my application together with $50 cash payment (exact amount only), or did I attach a money order for fifty dollars ($50.00) made payable to “Treasurer, City of New Haven?” (If no, your application is not complete, unless applying for waiver.)
Step 4 -- Do I have a financial hardship that allows waiving my application fee? Do I meet the
Income
Guidelines?
If no, make sure to follow Step 3. If yes:
Did I fill out the Waiver of Fee section of the Application Fee/Waiver Form and attach to my completed application? (If no, your request to waive the fee is not complete.)
Step 5
--Voluntary Survey Form
Did I supply the information requested? The information requested is extremely helpful to us in evaluating our recruitment efforts.
Step 6
--Do I currently possess a CPAT certificate that I acquired on or later than April 1, 2012?
If no, skip this step. If yes:
Did I attach a copy of my CPAT certificate to my completed application? (If no, you must take the New Haven physical agility test. If you acquire a CPAT certificate before your scheduled test date, you may waive testing by coming to the test site on the date and time scheduled, and submit a copy of your CPAT certificate.)
Step 7
--Am I a New Haven resident wanting preference points, or wanting to take the test
orientation course? If no, skip this step. If yes:
Did I attach a completed Preference Points form with photocopies of 3 items proving my domicile? (If no, extra points will not be added to your final passing exam score.)
Did I attach completed Gateway Community College forms with proof of domicile to take the orientation course? (If no, you cannot attend the course).
Step 8
--Am I a war-time, or disabled war-time veteran wanting extra points? If no, skip this step.
If yes:
Did I attach a copy of my DD-214? If disabled, did I additionally attach a copy of my disability rating? (If no, extra points will not be added to your final passing exam score.)
Step 9
--Submit the Application Packet
Application Packets must be submitted IN PERSON no earlier than 9:00 am on March 11, 2013 and no later than 5:00 pm on March 22, 2013 to: Fire Training Academy - Department of Fire Service 230 Ella T. Grasso Boulevard New Haven, CT 06519 Monday – Friday, 9:00 am – 5:00 pm.
APPLICATIONS RECEIVED AFTER 5:00 PM ON THE DEADLINE DATE WILL NOT BE ACCEPTED. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Y O U M U S T S H OW Y O U R C U R R E N T D R I V E R ’ S L I C E N S E W H E N S U B M I T T I N G Y O U R A P P L I C AT I O N .
Optional Step
--Do I need a disability-related accommodation in the Civil Service Exam process?
If yes, make sure to complete the ADA Accommodation Request Form and follow all instructions on the form. DO NOT ATTACH ADA FORM TO YOUR COMPLETED APPLICATION.
REMINDER MESSAGE FROM THE NEW HAVEN FIRE DEPARTMENT
Even before you participate in the Civil Service exam process, you should start assembling the
following documents. If you pass all parts of civil service testing and are ranked high on the
eligibility list, the Fire Department may contact you with a conditional offer of employment. At
that time you will need to submit the following documents to the Fire Department:
Copy of Birth Certificate
Copy of Social Security card
Copy of Driver’s License (
at the time of conditional offer of employment, out-of-state
candidates must obtain a Connecticut Driver’s License
)
Copy of Vehicle Registration (if applicable)
Copy of High School Diploma or GED
Copy of College Degree (if applicable)
Copy of Military DD 214 Form (if applicable)
Marriage License (if applicable)
Divorce Paperwork (if applicable)
Proof of US citizenship (if born abroad)
Applicants who cannot locate or do not have these materials are advised to begin
FIREFIGHTER RECRUITMENT – 2013
APPLICATION PACKET
FORMS SECTION
-
Application Fee/Waiver Form
-
Waiver Eligibility Guidelines
-
Affidavit Regarding Age, High School Completion & Driver’s License
-
Residency Preference Points Form
-
Preference Points Statement Sheet
-
Gateway Community College Entry-Level Firefighter Test Orientation
Course Reservation Form
-
Gateway Community College Entry-Level Firefighter Test Orientation
Course Registration Form
-
Voluntary Survey Form
-
ADA Testing Accommodation Request Form
APPLICATION FEE/WAIVER FORM
FIREFIGHTER RECRUITMENT - 2013
The New Haven Department of Fire Service charges a fifty dollar ($50) application fee to defray the cost
of recruiting, testing and hiring firefighter applicants.
The amount (
cash or money order
only
) must be paid at the time the completed application is submitted.
This application fee is
NON-REFUNDABLE
regardless of whether applicants complete all phases of
testing and hiring.
The Department will waive the fifty dollar ($50) application fee in cases of financial hardship based on the
2013 HHS Poverty Guidelines. One of the phases of the hiring process will include a background
investigation in where certain documents will be required including income tax forms. If the Department
learns at that time that an applicant did not meet the income guidelines, had the ability of paying the
application fee and that a request to waive the fee was fraudulent, the candidate will be dropped from
further consideration in the selection process.
I understand that if I proceed to the Oral examination, I will be required to pay an additional $30 Testing
Fee that I will be required to submit at that time for entry to that exam.
_______________________________________ ________________________________________ Name of Applicant (please print) Signature of Witness HR Staff
_______________________________________ ________________________________________
Signature of Applicant Date
A.
Check Here if Paying Application Fee
:
(To be filled out by personnel of New Haven Human Resources)All
applicants
must
print/sign
here
On this date,____________________, firefighter applicant __________________________________________
Date Name of Applicant (please print)
paid a NON-REFUNDABLE fifty dollar fee via(circle one) CASH MONEY ORDER as the application fee for the position of New Haven Firefighter.
__________________________________________________________ Signature of HR Personnel
B.
Check Here if
Waiving Application Fee:
I have read and understand the above statement in its entirety. I have reviewed and certify that I meet the eligibility guidelines. I hereby declare that I cannot afford to pay the fifty dollar ($50) application fee. I certify that this
2013 Updated Waiver Eligibility Guidelines
The following figures are the 2013 HHS poverty guidelines which are scheduled to be published in the
Federal Register
on January 24, 2013. (Additional information will be posted after the guidelines are
published.)
2013 Poverty Guidelines for the
48 Contiguous States and the District of Columbia
Persons in
family/household Poverty
guideline
1
$11,490
2
15,510
3
19,530
4
23,550
5
27,570
6
31,590
7
35,610
8
39,630
For families/households with more than 8 persons,
add $4,020 for each additional person.
AFFIDAVIT
ATTESTING TO MY AGE, HIGH SCHOOL COMPLETION & DRIVER’S LICENSE
I,
, by completing and signing this
(APPLICANT PRINT NAME HERE)
affidavit form do hereby attest that
(please check boxes below):
I am 18 years of age as of the date of this affidavit as required by the minimum requirements to apply tobecome a Firefighter in the New Haven Department of Fire Services.
I currently possess a high school diploma or GED certificate as required by the minimum requirements to
apply to become a Firefighter in the New Haven Department of Fire Services.
As of the date of this affidavit, I possess a valid driver’s license as required by the minimum requirements to
apply to become a Firefighter in the New Haven Department of Fire Services.
I understand that if I sign and submit this affidavit and it is later discovered during any part of the selection
process for the position Firefighter that I do not meet the requirements stated above, I will be considered to have
falsified information in my application for the position of Firefighter and I will be disqualified from continuing
in the process.
I further understand that signing this affidavit does not release me from the requirement to produce valid copies
of my birth certificate, high school diploma or GED certificate, and driver’s license if extended a conditional
offer of employment.
I sign this release voluntarily and without coercion or duress.
CITY OF NEW HAVEN CIVIL SERVICE
APPLICATION FOR PREFERENCE POINTS – CITY OF NEW HAVEN DOMICILED
A person domiciled in the City of New Haven may have 5 points added to his or her passing score on an open competitive examination. In order to qualify for preference points in accordance with Civil Service Rules and Regulations, the Civil Service Division of the City of New Haven Department of Human Resources requires that you provide irrefutable evidence to substantiate that you were domiciled in the City of New Haven at the time of the announcement of the open competitive exam to which you request to have the residency points applied.
As the intention of the applicable Civil Service Rule is to give those domiciled in the City of New Haven preference points on open competitive examinations, the Personnel Director is authorized to require proof that an applicant meet all the conditions of domiciliary status set forth above.
For the purpose of this Application for Preference Points, “DOMICILED” is defined as “that place where an individual has his or her true, fixed, and permanent home and principal establishment, and to which whenever he or she is absent, he or she has the intention of returning. The permanent residence of a person or the place to which he or she intends to return even though he or she may actually reside elsewhere.”
You are required to complete and submit this form as part of the employment application process. You must follow all instructions and answer all questions listed on this form. You must provide copies of the items proving you are domiciled in the City of New Haven as instructed in this form, and you must be prepared to submit any additional documentation as the Personnel Director may require. Application for preference points will not be honored without proof. In the case of insufficient proof, your application for preference points will be rejected.
NOTE: The applicant bears the burden to show legal domicile. The information and responses you provide on this form are subject to verification by the Civil Service Division. Any false or misleading statements will result in immediate disqualification or dismissal if hired.
Please note that these points will only be added to passing scores and applied up to the maximum score on a scale of one-hundred (100) points. The passing score for any civil service examination is 70%.
Y O U M U S T C O M P L E T E T H E F O L L O W I N G S E C T I O N :
Title of Open Competitive Exam You Applied For:
(P L E A S E P R I N T)
Name of Applicant:
(P L E A S E P R I N T)
I, , hereby attest that I am a bona fide resident of the City of New
(Name of Applicant)
Haven, who as of the date of the announcement of the open competitive examination indicated above, was domiciled within the City of New Haven at the address shown below.
(A P P L I C A N T A D D R E S S)
I have been domiciled at the above address since: : / /
Mo. Day Year
I have been domiciled in New Haven since: / /
Mo. Day Year
L I V I N G A R R A N G E M E N T
Y O U M U S T C H E C K O N E ( 1 ) O P T I O N T H A T A P P L I E S T O Y O U : [ ] I own and I am domiciled at the address shown above.
[ ] I rent and I am domiciled at the address shown above. My Landlord’s address and telephone number is:
(Name and Address of Landlord) (Landlord Phone Number)
[ ] I do not own or rent at the address shown above. The following explains my current living arrangement: (Explain)
Eligibility: You must provide a minimum of 3 items to show you are domiciled within the City of New Haven. Y O U M U S T C H E C K O N E ( 1 ) O P T I O N T H A T A P P L I E S T O Y O U I N E A C H S E C T I O N B E L O W . PICTURE IDENTIFICATION - Evidence to substantiate my claim for preference points is provided as follows:
Y O U M U S T C H E C K O N E ( 1 ) O P T I O N T H A T A P P L I E S T O Y O U :
[ ] I have an Elm City Resident Card and I am still domiciled at the address shown on my Elm City Resident Card. I have attached a copy to this form. I understand I still need to supply
two (2)
more items proving my domicile.[ ] I have an unexpired driver’s license and I am still domiciled at the address shown on my unexpired driver’s license. I have attached a copy to this form. I understand I still need to supply
two (2)
more items proving my domicile.[ ] I have a valid picture ID and I am still domiciled at the address shown on my valid picture ID. I have attached a copy to this form. I understand I still need to supply two (2) more items proving my domicile.
[ ] I have a valid picture ID that does not show my current address. I have attached a copy to this form. I understand I need to supply
three (3) more
items proving my domicile.ADDITIONAL ITEMS PROVING DOMICILE - Evidence to substantiate my claim for preference points is provided as follows:
Y O U M U S T C H E C K O N E ( 1 ) O P T I O N T H A T A P P L I E S T O Y O U :
[ ] I checked-off above that I am providing Picture Identification showing the address where I am currently domiciled. Attached are copies of
two (2)
items such as current utility bills (gas, electric, etc) other bills (insurance, credit card, etc.), or other official business mail (bank statements, etc.) that I have received within the last 60 days.[ ] I checked-off above that the Picture Identification that I am providing does not show the address where I am currently domiciled. Attached are copies of
three (3)
items such as current utility bills (gas, electric, etc) other bills (insurance, credit card, etc.), or other official business mail (bank statements, etc.) that I have received within the last 60 days.Note: (Bills or other material you have received in the mail and want to submit as proof of domicile cannot be more than two (2) months old. Submitted copies must clearly show name, address and date on item you are submitting. You may blacken out information such as account numbers, etc. Personal hand-written mail IS NOT ACCEPTED.)
Applicants, who are unable to provide proof of domicile, are not eligible to apply for Preference Points.
Attach this form to the copies of the items you indicated above to prove residency. WE CANNOT MAKE COPIES OF ITEMS FOR YOU AT THE APPLICATION SITE. Photocopies of a total of three (3) items are required and all three (3) items must show your name and address.
Special Note
This form and the items for verification of domicile must be presented at time of application. You cannot apply for preference points for the open competitive exam indicated on this form after applying for the position.
PLEASEREADCAREFULLYBEFORESIGNINGBELOW
I hereby certify that ALL statements made by me on this Application for Preference Points are true, complete and correct; that the address listed above is my domicile as of the date of the job announcement for the position to which I am applying; and that I currently live at this address on a continuous basis. I understand and agree that if I provide false or inaccurate information
regarding my domicile, I will be subject to immediate disqualification, removal of my name from the Eligibility list, or dismissal if employed, and to such other penalties prescribed by law. I hereby request five (5) points be added to my final passing score. I understand that preference points will be added to my final score if I pass the examination with a score of 70% or higher, and that
CIVIL SERVICE BOARD
CITY OF NEW HAVEN
200 O
RANGES
TREETNEW HAVEN, CT 06510 Telephone 203-946-6488
PREFERENCE POINTS STATEMENT SHEET
Check the item that applies to you, then print your name and sign and date the bottom:
_____ I did not apply for veteran's preference points
_____ I did not apply for residency preference points because:
_____ I am not a New Haven resident
_____ I am a New Haven resident, but I choose not to apply
_____ I lack sufficient documentation to show that I am a New Haven resident
Title of position I am applying for today:
_______________________________________________________________________
_________________________________________
Print Name Here
_________________________________________
_________________
VOLUNTARY SURVEY
New Haven Firefighter Recruitment Outreach Campaign -- 2013
Your participation is voluntary, but extremely helpful. This form does not affect the status of your
application. The data requested is used by the New Haven Human Resources Department to evaluate
our efforts in recruiting and maintaining a diverse workforce.
Last Name ________________________ First Name _______________________ M.I. _____
Street Address ____________________________________________________________________
City _______________________________ State ________ Zip Code ______________
Home Phone ____________________ Work Phone ___________________ Cell Phone ____________________
Social Security No. ____________________________ Sex ________
How would you identify yourself? You may check more than one response.
_____ African American/Black _____ Caucasian/White _____ Native Hawaiian or other Pacific Islander
_____ American Indian _____ Latino/a _____ Two or More Races (Native American)
_____ Asian _____ Other
(please specify) ____________________________
Where did you learn about this campaign? (Check as many as are appropriate.)
_____ Newspaper (specify________________________) _____ NHFD Department member _____ Television announcement or feature _____ Word of Mouth_____ Radio announcement or feature _____ Job Fair (specify where___________________________) _____ College visit _____ Cultural Event in New Haven (e.g. Concert on Green,
Gospel Fest, Farmers Market)
_____ City of New Haven Website (specify______________________________________) _____ Other Website (specify_____________________) _____ Other (specify__________________________________)
Did you attend any of the Open House events?
D
EPARTMENT OFS
ERVICES FORP
ERSONS WITHD
ISABILITIESCITY OF NEW HAVEN 165 CHURCH STREET NEW HAVEN, CONNECTICUT 06510 (203) 946-8122 - VOICE (203) 946-8582 -
TTY/TT
(203) 946-6934 - FAX
Applicant ADA Accommodation Request Form (2013)
Accommodation Requests Must Be Filed with the Department of Services for Persons with Disabilities Within 15 Business Days of the Job Posting Removal Date
APPLICANT’S NAME: DATE:
ADDRESS:
PHONE:
TEST DATE: POSITION:
The Americans with Disabilities Act (ADA) enables qualified applicants with substantial impairments that effects one or more major life activities the opportunity to request a reasonable modification to the City’s policies, practices and procedures to enable them to apply and/or test for a position with the City. We will need from the applicant information related to his or her disability to determine what accommodation may be best for the applicant.
What you need to know about the accommodation process:
1. All information provided to the Department of Services for Persons with Disabilities is confidential and will only be used to provide an appropriate accommodation to applicants with disabilities whom have requested an accommodation. 2. Most applicants who request an accommodation will be asked to submit medical documentation to verify that they are a
person with a disability as defined in the ADA.
3. Individuals requesting an accommodation for a learning disability will need to provide documentation from a health care provider describing the type of learning disability.
4. All information and documentation submitted from a health care provider must be written within the previous twelve (12) months to the date of application to insure that the accommodation meets the current needs of the applicant. 5. Any health care provider used to support this application must be willing and able to speak knowledgeably about the
disability and willing to work with our staff in determining the best accommodation for the applicant.
6. All supporting documentation must be presented no later than 15 days after the job posting “REMOVAL DATE.” To process your request for an accommodation we need the following information:
DESCRIBE HOW YOUR HEALTH ISSUE OR IMPAIRMENT AFFECTS YOUR LIFE:
DESCRIBE WHAT ACTIVITIES IN YOUR DAILY LIFE ARE RESTRICTED BY YOUR HEALTH ISSUE OR IMPAIRMENT:
WHAT ACCOMMODATIONS DO YOU FEEL WILL ENABLE YOU TO APPLY FOR AND/OR TEST FOR THIS POSITION WITH THE CITY.
PLEASE DESCRIBE IN DETAIL.
PLEASE PROVIDE THE NAME AND PHONE NUMBER OF YOUR CURRENT TREATING HEALTH CARE PROVIDER THAT CAN SPEAK TO YOUR CURRENT LIMITATIONS. BE SURE TO CONTACT YOUR HEALTH CARE PROVIDER TO SIGN THE NECESSARY RELEASES OF INFORMATION SO THAT THIS DEPARTMENT MAY DISCUSS WITH THEM YOUR CONDITION AND WHAT
ACCOMMODATIONS WILL WORK BEST. ALL MEDICAL INFORMATION PROVIDED TO THE DEPARTMENT OF SERVICES FOR PERSONS WITH DISABILITIES IS STRICTLY CONFIDENTIAL AND WILL ONLY BE USED IN EVALUATING THIS ACCOMMODATION REQUEST.
HEALTH CARE PROVIDER’S NAME:
PHONE:
I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REQUEST IS A TRUE AND ACCURATE. DATE:
CITY OF NEW HAVEN
An Equal Opportunity EmployerAPPLICATION FOR EMPLOYMENT
COMPLIES WITH ALL FEDERAL AND STATE ANTIDISCRIMINATION LAWS
Department of Human Resources, 200 Orange Street New Haven, Connecticut 06510 Phone: (203) 946-8252 1. Job Applying For (one title per application):
2. Your Name: (Print)
Last Name: First Name: Middle:
3. Address:
Number and Street:
4. Contact Telephone Number:
City: State: Zip:
Email Address:
5a. Are you currently employed by the City of New Haven, including the Board of Education? Yes No 5b. Were you, at any time, previously employed by the City Of New Haven, including the Board of Education? Yes No
If "Yes," to 5b, list Department, Title(s) and dates of employment:
6. Social Security Number: (Optional) 7. Are you at least 18 years of age? Yes No 8. EDUCATION / TRAINING:
a. List last high school or trade school you attended:
NAMEOFSCHOOL LOCATION CIRCLE LAST GRADE COMPLETED DIPLOMA / GED RECEIVED?
9 10 11 12 Yes No
b. List any colleges, graduate schools, business schools or technical schools attended:
NAME OF SCHOOL LOCATION MAJOR TYPE OF DEGREE /CERTIFICATE
c. Do you have a current Driver’s License?
Yes No If yes, indicate issuing State: _______________________ Exp Date: ___________________ Endorsements, if any: __________________________
Do you have a current Commercial Driver’s License?
Yes No If yes, indicate issuing State: ___________________ Exp Date: ___________________ Class: ___________________________________
d. Specialized training and skills: List any other trade licenses or certifications, skills and training you have related to the job for which you are applying. Include machines you can operate, computer skills, and additional languages you are fluent in.
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 9. Work Experience: Start with your present or most recent employment experience, and working backward, list all paid or unpaid, full or part-time work, military service, summer jobs, and volunteer work performed during the last 10 years. List all pertinent information related to the job for which you are applying. (If more space is required, attach additional sheets or your resume).
1 Starting Date:
Month Year
Ending Date:
Month Year
Name and Address of Employer:
Hours per Week: Name and Title of Immediate Supervisor: May we Contact? Yes No If No, why?:
Reason for Leaving: Your Present or Last Job Title: Your Duties:
CITY OF NEW HAVEN
An Equal Opportunity EmployerAPPLICATION FOR EMPLOYMENT
COMPLIES WITH ALL FEDERAL AND STATE ANTIDISCRIMINATION LAWS
Department of Human Resources, 200 Orange Street New Haven, Connecticut 06510 Phone: (203) 946-8252 - Work Experience Continued -
2 Starting Date:
Month Year
Ending Date:
Month Year
Name and Address of Employer:
Hours per Week: Name and Title of Immediate Supervisor: May we Contact? Yes No If No, why?:
Reason for Leaving: Your Job Title: Your Duties:
3 Starting Date:
Month Year
Ending Date:
Month Year
Name and Address of Employer:
Hours per Week: Name and Title of Immediate Supervisor: May we Contact? Yes No If No, why?:
Reason for Leaving: Your Job Title: Your Duties:
10. CERTIFICATION: I certify that all statements made on or in connection with this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that incomplete, false or inaccurate information, regardless of when it is discovered, may result in the rejection of this application or my dismissal if employed.
