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Fire Department Security Screening Form

  1. Please choose “yes” or “no” on each of the following questions:

    Have you ever been convicted of, entered a guilty plea to, a plea of nolo contendere to, or a no contest or equivalent plea to any of the following charges:

  2. High School graduate or equivalent?*

  3. Currently 21 year of age?*

  4. US Citzen or possess legan authorization to work in the United States?*

  5. Ability to read and write English?*

  6. Valid Drivers License?*

  7. Possess a current National registry EMT license and or Oklahoma state basic EMT or higher?*

  8. Have you ever been convicted of, entered a guilty plea to, a plea of nolo contendere to, or a no

  9. Any felony?*

  10. Any fire-related crime?*

  11. Any theft-related crime?*

  12. Any burglary-related crime?*

  13. Any sexual assault-related crime?*

  14. Any stalking or personal assault-related crime?*

  15. Any impersonation or falsification-related crime?*

  16. Any intimidation, harassment or threat-related crime?*

  17. Any drug, narcotics or substance abuse-related crime?*

  18. Any careless, imprudent, reckless, or negligent driving convictions?*

  19. Any fraud, dishonesty, misrepresentation or license-related crime?*

  20. Any crime or violation of law, regulation or rule that will prevent the applicant/candidate from obtaining or maintaining the required EMS license(s)?*


  21. Have you ever experienced any of the following events:

  22. Loss of driver’s license due to suspension or revocation for 90 or more days at any time in the past?*

  23. Three or more moving violations in the 36 months immediately preceding background check or five or more moving violations in the 60 months preceding background check date?*

  24. Conviction of, plea of guilty to, plea of nolo contendere to, a plea of no contest or equivalent in connection with operation of a motor vehicle while under the influence of alcohol, drugs or other subtances?*

  25. Conviction of, plea of guilty to, plea of nolo contendere to, a plea of no contest or equivalent in connection with hit-and-run, manslaughter or similar crime while operating a motor vehicle?*

  26. Any aggressive use of a vehicle that posed a hazard to persons or property?*

  27. Leave This Blank:

  28. This field is not part of the form submission.