Public Safety Recruitment 1127 S. Mannheim Rd., #203 Westchester, IL 60154 www.publicsafetyrecruitment.com [email protected] 800-343-HIRE

VILLAGE OF HINSDALE FIREFIGHTER/PARAMEDIC APPLICANT INSTRUCTIONS Applicants must meet a variety of qualifications, as specified in the Rules and Regulations of the Board and State Statutes, including but not limited to the following:  Shall be between the ages of 20 and 35 years of age at the time of application deadline (unless statutorily exempted by 65 ILCS 5/10-2.1-6)  Has qualified for and received State of Illinois certification as an Emergency Medical Technician/Basic, Emergency Medical Technician/Intermediate, or Emergency Medical Technician/Paramedic  Successful completion of the Candidate Physical Ability Test (CPAT) through a licensed agency within one year PRIOR to 12/13/10*  Has a high school diploma or has an equivalent high school education  Citizen of the U.S. or Permanent Resident who has applied for citizenship  Valid Driver's License  Be in good physical health  Be of good moral character  Applicants shall not have any tattoos that would be visible in whole or in part while wearing any uniform or apparel of the department  Vision examination to determine if his or her vision meets department standards  Submission of Online Application and requested documentation (see CHECKLIST) by NOON on Monday, December 6, 2010.  $25 Application Fee** To apply: 1) Visit www.publicsafetyrecruitment.com to complete the Online Application for the position of Firefighter/Paramedic. Your online application must be confirmed no later than 12 noon on Monday, December 6, 2010 . You will receive a confirmation number when you complete your online application. Save this number for your records. 2) Return the signed Release Forms and Other Required Documents (See CHECKLIST) to Public Safety Recruitment (1127 S. Mannheim Rd., #203 Westchester, IL 60154 Attn.: Hinsdale FD) no later than 12 noon on Monday, December 6, 2010. Applications and Documents received after the deadline will not be accepted. Faxed release forms will NOT be accepted. Sending release forms and other required documents via traceable carrier is suggested to ensure timely delivery. Documents may also be delivered by hand to Public Safety Recruitment during business hours (M-Th 9a-5p, F 9a-3p). Call 800.343.HIRE or email [email protected] with questions. Mandatory Orientation: Attend Orientation Monday, December 13, 2010 at Village of Hinsdale Board Room, 19 E. Chicago Avenue, Hinsdale, Illinois 60521. Sign in from 6:00 to 7:00 p.m.; Orientation program begins at 7:00 p.m. – NO ADMITTANCE AFTER 7:00 p.m. Must present a valid Driver’s License or State ID, your valid CPAT Card AND your ORIGINAL State of Illinois EMT Certification (Basic, Intermediate or Paramedic) to sign in. Physical Ability Test: Provide proof of successful completion of the Candidate Physical Ability Test (CPAT) through a licensed agency. CPAT certification considered valid ONLY if issued within 1 year PRIOR to December 13, 2010. **Licensed CPAT testing agencies: NIPSTA, Glenview, IL http://www.nipsta.org/CPAT/CandidateInformation.aspx, Southwest United Fire Districts, Darien, IL – www.SUFD.org

Written Examination: Written Test will be conducted on Saturday, January 8, 2011 at Hinsdale Middle School, 100 S. Garfield, Hinsdale, IL 60521. Arrive at 8:30 a.m. to sign-in with your valid driver’s license or state ID. Testing will begin promptly at 9 a.m.

Oral Interviews:

Oral Interviews for passing candidates will be determined at a later date. Notifications will be mailed and emailed to eligible candidates.

Compensation: Excellent Benefits plus Step Pay Plan Entrance: $55,196/year Top salary- step plan plus merit- $83,022/year If you do not attend or do not complete any portion of the testing process, you will not be eligible for employment. The Village is an Equal Opportunity Employer and does not discriminate on the basis of race, color, creed, religion, sex, age, national origin, place of residence, marital status, political affiliation or disability. If you are an individual with a disability and would like to request a reasonable accommodation for any one of the areas listed above, please notify the Hinsdale Fire and Police Department at 630-789-7070 (TDD accessible). **The application fee can be waived for candidates experiencing financial hardship. For details, send an email to [email protected].

CHECKLIST

HINSDALE FIRE DEPARTMENT Online Application

DEADLINE: Noon on December 6, 2010

 CONFIRMED Online

WRITE YOUR CONFIRMATION NUMBER HERE:___________ (The confirmation page immediately follows the references section of the online application)

Release Forms (see pages 1-6)

DEADLINE: Noon on December 6, 2010

*No photocopies or fax copies of the required release forms will be accepted. You must submit the ORIGINAL DOCUMENTS WITH INK SIGNATURES. Acceptable witness signatures include adult family members and friends residing within the US.

 Village of Hinsdale Agreement, Waiver, and Indemnification* (2 pages)  Alcohol, Drug and Substance Abuse Screening*  Criminal History Information/ Fingerprint*  Driving Record*  Medical Records*

Other Required Documents

DEADLINE: Noon on December 6, 2010

 COPY of High School Diploma or equivalent (GED)

(Copy of high school transcripts with graduation date, dated GED,

or signed letter on high school letterhead is acceptable.)

 COPY of valid Driver’s License

(copy of front and back if you received a renewal sticker)

 CERTIFIED COPY of Birth Certificate (i.e.: State or County issued birth certificate).

Hospital copy NOT accepted.

 COPY of Naturalization Papers (if born outside U.S. territories)  COPY of State of Illinois Certifications as EMT-B, EMT-I, or EMT-P (NOTE: ORIGINAL Certification, along with your valid Driver’s License or State ID, is required at Orientation) *If you have any questions regarding the application process or requirements, or if you are a legal alien, contact Public Safety Recruitment before the application deadline. 800.343.HIRE [email protected] Applications will not be verified until after the deadline has passed. Candidates who submit applications lacking proper documentation as indicated above will not be admitted to orientation or testing and you will be eliminated from employment consideration. I/O Solutions Inc., d.b.a. Public Safety Recruitment, is not responsible for late, misdirected or incomplete application submissions. You must submit all required documents and have successfully CONFIRMED your online application by the deadline in order to be eligible to attend any portion of testing. You may drop your application documents off in person or by mail; however, all documents including your online application are due by the deadline as indicated.

CALL 800.343.HIRE WITH QUESTIONS PLEASE SUBMIT RELEASE FORMS & OTHER REQUIRED DOCUMENTS TO:

PUBLIC SAFETY RECRUITMENT A T T N . : Hinsdale FD 1127 S. MANNHEIM ROAD, SUITE 203 WESTCHESTER, IL

60154

DO NOT SUBMIT REQUIRED DOCUMENTS TO THE VILLAGE OR TO THE FIRE DEPARTMENT.

October 27, 2010 Village of Hinsdale Fire Department General Information & Benefits for Firefighter/Paramedics Salary Salary Grade Salary Range Starting Salary:

PS2 $55,196-83,022 (7 steps plus merit pool) PS2 - $55,196.00 Annually

Employees are eligible for advancement to the next step annually based upon satisfactory performance. Employees become eligible for the merit pool 1 year after reaching the final pay step. The merit pool is awarded annually as a percentage increase based upon above average performance. Employees may receive cost of living adjustments effective May 1st of each year. 1.

Health Insurance - The Village provides employees two different HMO plans and a High Deductible PPO Health Plan (HDHP). The Village currently pays 100% of the employee coverage for the HMO plan. In addition, the Village pays 90% of the dependent coverage for the HMO plans with the employee paying the remaining 10% (currently $96.90/month for HMO IL and $94.29/month for HMO Blue Advantage). For the HDHP, employees don’t contribute towards the premium, but there is a $5000 annual deductible for family coverage and $2500 for single coverage. The Village contributes $1500 towards the deductible for family coverage and $750 for single coverage.

2.

Dental Insurance - The Village currently pays the full cost of dental insurance for the employee. Dependent coverage is available at a current monthly cost to the employee of $60.97.

3.

Life Insurance – Employees are provided life insurance coverage at 1¾ times salary (up to a maximum $200,000) with the premiums 100% paid by the Village. Voluntary supplemental coverage is available for the employee and dependents at nominal amounts.

4.

Salary - The starting annual salary for firefighter/paramedics is $55,196. Employees are paid bi-weekly on Friday for a total of twenty-six (26) pay periods per year.

5.

Vacation - 106.4 hours vacation time is granted to the employee after the first year, 159.6 hours after five years, 212.8 hours after ten years, and 266.24 hours after twenty-two years.

6.

Holidays - 106.4 hours are given in lieu of holidays which may be taken throughout the year upon the employee's request and subject to departmental approval.

7.

Sick Leave - Sick leave is accrued from the first day of employment. Each full-time employee shall accrue 10.64 hours per month for sick days. Sick Leave Bonus - If no sick leave is used during the year, 31.92 hours bonus pay will be added to your post employment health insurance account. Employees who leave the Village after ten years of service will be compensated for a portion of their unused sick leave via a contribution to your post employment health insurance account.

8.

Special Leave - granted at discretion of Department Head due to serious illness or death of immediate family member (maximum 24 hours).

9.

Personal Leave - Employees are entitled to 10.64 hours of personal leave per year subject to department approval.

10. Family & Medical Leave and Military Leave - Leave time is provided as required by state and federal law. 11. Pension - The firefighter/paramedic is eligible to join the firefighter’s pension fund upon application. 8.445% shall be deducted from the firefighter/paramedic’s current salary as his/her contribution to the pension fund. The Village contributes to the pension fund according to actuarial requirements. The Firefighters Pension Fund is administered according to State law, which may be changed by the Illinois General Assembly from time to time. Voluntary Retirement: (current Statute)

Eligibility: Age 50 with 20 years of service Amount – the annual benefit amount is equal to the product of final pay times the sum of : (1) 50%, plus (2) 2½% for each year of service in excess of 20 years but less than 30 years. The maximum benefit is 75% of final pay. General Information & Benefits, 1 of 2

12. Probation – Each person appointed to the entry level rank in the Fire Department shall be on probation for a period of 12 months after the date of appointment and may be extended by the Board as permitted by law. 13. Uniforms - Uniforms are supplied by the Village. The employee is required to maintain all equipment in good condition. 14. Outside Employment - Any outside part-time employment must be approved by the Fire Chief. 15. Work Hours - The firefighter/paramedics work 24-hour shifts with 48 hours off unless otherwise designated by Fire Chief. 16. Longevity - Employees currently are eligible to receive a longevity bonus after achieving 10 years of service with the Village of Hinsdale. This annual bonus is currently $500 for employees with 10 to 14 years of service, $600 for 15 to 19 years, $700 for 20 or more years. 17. Residency – Each full-time member of the Fire Department shall reside within the Greater Chicago Metropolitan Area, that is, within one of the following counties: Cook, DuPage, Kane, Lake, McHenry, or Will. A full-time member shall have one year after completion of his/her probationary period within which to comply with this residency requirement. 18. Kelly Days - In order to comply with the Fair Labor Standards Act, employees of the Hinsdale Fire Department will work no more than 167 hours during a 22-day pay cycle (they will receive approximately 6 Kelly Days each year). Department members are paid every 2 weeks. 19. All appointments (except for Fire Chief and Deputy Fire Chief and civilian personnel) to the Fire Department are made by the three-member Board of Fire and Police Commissioners, who are appointed by the Village President and Board of Trustees. 20. Firefighter/Paramedics shall obtain and maintain certifications and/or specialties as are required and/or deemed necessary for the effective operation of the Fire Department. All candidates shall become certified as Illinois State Certified Firefighter II, Hazardous Materials First Responders, and Confined Space Awareness prior to completion of their probationary period. A Firefighter/Paramedic shall become an Illinois State Certified Firefighter III and Fire Apparatus Engineer within three (3) years of his/her initial date of employment. Other certification and/or specialties deemed necessary include, but are not limited to, those within the areas of fire suppression, emergency medical services, rescue, fire prevention and investigation, hazardous materials, and public education. All required certifications and/or specialties obtained shall be maintained at all times. 21. Section 125 Pay Plan - The Village offers a tax deferred plan to allow employees to shelter health care and child care costs plus take advantage of several voluntary programs. 22. 457 Deferred Income Plan - The Village offers two Deferred Income Plans that allow employees to defer income to the current maximum of $16,500 per year. 23. Credit Union - Village employees have the option of participating in the DuPage Credit Union. 24. Harris Bank – Village employees are eligible to participate in Harris Bank’s Bank at Work program. 25. Post Employment Health Plan – Village employees contribute 1% of salary on a tax-exempt basis plus conversion of other benefits to this plan, which provides for funding of health insurance benefits after separation from the Village. 26. Employee Assistance Program – Village employees and their families are able to participate in the Village’s EAP program. The program includes mental health benefits as well as various work/life programs. The Village of Hinsdale is an Equal Employment Opportunity Employer.

General Information & Benefits, 2 of 2

VILLAGE OF HINSDALE VOLUNTARY STATEMENT OF AGREEMENT, WAIVER AND INDEMNIFICATION BY APPLICANT FOR FIREFIGHTER/PARAMEDIC

I am an applicant for the position of Firefighter/Paramedic with the Village of Hinsdale. As a part of my voluntary decision to apply for this position, I understand and agree to the following items: 1. I will cooperate with the Hinsdale Board of Fire and Police Commissioners’ testing program by submitting to the examinations provided by the Board in the Rules and Regulations, a copy of which will be available to me upon request. 2. I understand that, as part of the testing program for the position of Firefighter/Paramedic, I will be required to take certain examination elements, and I am willing to participate in all of these elements. The elements are as follows: Orientation, Physical Agility Test, Written Test, Preliminary Character and Background Investigation, Polygraph Examination, Initial Oral Test, Performance Potential Assessment, Detailed Character and Background Investigation, Final Oral Test, Psychological Test, and Medical Test. This testing program will take approximately two and a half months to complete. In addition, I understand that all examination documents and the results thereof become the property of the Hinsdale Board of Fire and Police Commissioners and that I will not be allowed to review the specific grading of, or information or reports resulting from, any element of the examination. 3. I understand that I will take a physical agility test and other examinations that could pose risks of serious bodily injury or death to me. I certify that I am unaware of any physical condition which would endanger me while undertaking the test administered by the Board. I undertake such testing freely and voluntarily, and I hereby WAIVE, and RELEASE and discharge the Hinsdale Board of Fire and Police Commissioners and the Village of Hinsdale and its officers, agents, employees, and testing agencies and contractors from, any and all claims for damages, losses, or injury that I may have or that I may suffer in connection with any aspect of such testing, including without limitation any physical agility test and any investigation of my background. 4. I further agree to indemnify and hold harmless and defend the Hinsdale Board of Fire and Police Commissioners, and the Village of Hinsdale and its officers, agents, and employees, from any and all claims for damages, losses, or injury, including death, which may arise or may be alleged to have arisen out of my participation in the process of being considered for employment with the Village of Hinsdale. 5. I hereby authorize the Hinsdale Board of Fire and Police Commissioners, and any consumer reporting agency or other outside agent, consultant or contractor of the Board of Fire and Police Commissioners engaged for this purpose from time to time to obtain, investigate, prepare, use and furnish information and records regarding my current and former employment, my education, my general reputation, personal characteristics, mode of living, and my acquaintances and references, past and present and up to the time of employment. I understand that submission of this document as part of my application for employment and its acceptance by the Board for consideration does not in any way obligate the Village of Hinsdale. I agree to execute the necessary releases from time to time as required in order for the Board to receive the requested documentation, including without limitation a release to allow the Board of Fire and Police Commissioners to obtain a consumer credit report about me. Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 1 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.

6. I hereby agree that, in consideration of seeking and being considered for employment by the Village of Hinsdale, I willingly submit to a polygraph examination, with emphasis on honesty and reliability traits, either prior to or during my course of employment. 7. If offered a position as a Firefighter/Paramedic, I agree that I will notify the Board of Fire and Police Commissioners of my decision in the time required by the Rules and Regulations. If I accept the position, I will terminate my other employment at that time, following provision of prompt and reasonable notice to my employer at that time, and will commence such training and duties as I may be directed to perform in the position of Firefighter/Paramedic. 8. If employed in the position of Firefighter/Paramedic, I agree to abide by and conform to the rules and regulations as they exist or may be amended of the Hinsdale Board of Fire and Police Commissioners, of the Department in which I am employed, and of the Village of Hinsdale. 9. I hereby certify that all of the information contained in my application is true and correct. I authorize the Village of Hinsdale to conduct research in order to verify and confirm any of this information. I release the Hinsdale Board of Fire and Police Commissioners and the Village of Hinsdale and its officers, agents, and employees from all liability for all damages whatsoever in obtaining and furnishing information concerning me. 10. I understand that, if any of the information contained in my application and any supplementary information that I provide, including this document, are not true, I may not be considered for employment and I may be terminated if I am employed by the Village. 11. I understand that, if I had applied in the past for the position of Firefighter/Paramedic and was not successful in obtaining the position, I am not precluded from reapplying at this time. Agreed to:

_________________________________

Date_______________________

Applicant Name, printed

_________________________________

Date_______________________

Applicant Signature

_________________________________

Date_______________________

Witness Name, printed

_________________________________

Date_______________________

Witness Signature DO NOT SUBMIT WITHOUT OBTAINING A WITNESS SIGNATURE FROM AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE U.S.

Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 2 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.

ALCOHOL, DRUG AND SUBSTANCE ABUSE SCREENING CONSENT I hereby consent for the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners or I/O Solutions, Inc., or either of its authorized representatives to collect blood, urine or saliva samples from me and to conduct other necessary medical tests to determine the presence in my body or use by me of alcohol, drugs or controlled substances. I understand that the presence of certain medications in my blood and/or urine may affect test results. To aid in the analysis of the test results I would like to inform the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners, I/O Solutions, Inc., and either of its authorized representatives that I have taken the following medications in the last seven (7) days:

________________________________________________________________________________

________________________________________________________________________________. RELEASE I understand that release of my medical records by this written authorization will result in disclosure of these test results. I hereby consent to the release of the test results and other relevant medical information to authorized representatives of the Village of Hinsdale, the Hinsdale Board of Fire and Police Commissioners, and I/O Solutions, Inc., its directors, officers, staff, employees, agents, representatives and assignees from any and all claims, demands, actions, fees and causes of action, suits at law, proceedings in equity, and liability that may arise by reason of the drug, alcohol and substance abuse screening or due to the disclosure of the test results as authorized herein by me. Agreed to:

_________________________________

Date_______________________

Applicant Name, printed

_________________________________

Date_______________________

Applicant Signature

_________________________________

Date_______________________

Witness Name, printed

_________________________________

Date_______________________

Witness Signature DO NOT SUBMIT WITHOUT OBTAINING A WITNESS SIGNATURE FROM AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE U.S.

Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 3 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.

CRIMINAL HISTORY INFORMATION / FINGERPRINT DISCLOSURE This is to inform you that in processing your application an investigation will be made whereby information is obtained from State and local law enforcement agencies for any reportable criminal history information concerning you using your fingerprints. This information can include a record of any convictions, which are required by statute to be collected and maintained by government agencies.

RELEASE

I agree to be fingerprinted by the Village of Hinsdale and acknowledge that these fingerprints will be used to investigate my criminal history and conviction record. I agree to and understand the release of the results of the investigation, to determine my criminal history information, will result in the disclosure of information concerning whatever criminal history exists regarding me to third parties. I hereby acknowledge the results of the investigation to determine my criminal history will be released to authorized representatives of the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners or I/O Solutions, Inc. for appropriate review and dissemination to those municipalities and/or Police/Fire departments (whichever is applicable) to which I have made application for employment or to which I will make application for employment. By executing this form I release, discharge and hold harmless the Village of Hinsdale, the Hinsdale Board of Fire and Police Commissioners, and I/O Solutions, Inc., its directors, officers, staff, employees, agents, representatives, and assignees from any and all claims, demands, actions, fees and causes of action, suits at law, proceedings in equity, and liability that may arise by reason of the investigation into my criminal history and the disclosure of any of that information. Agreed to:

_________________________________

Date_______________________

Applicant Name, printed

_________________________________

Date_______________________

Applicant Signature

_________________________________

Date_______________________

Witness Name, printed

_________________________________

Date_______________________

Witness Signature DO NOT SUBMIT WITHOUT OBTAINING A WITNESS SIGNATURE FROM AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE U.S.

Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 4 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.

DRIVING RECORD DISCLOSURE This is to inform you that in processing your application an investigation will be made whereby information is obtained from the Secretary of State regarding your driving record. This information can include a record of your current driver's license issuance information (exclusive of information on judicial driving permits); convictions and orders entered revoking, suspending, or canceling your driver's license or privilege.

RELEASE

I hereby acknowledge the results of the investigation of my driving record will be released to authorized representatives of the Village of Hinsdale or I/O Solutions, Inc. for appropriate review and dissemination to those municipalities and/or Police/Fire departments (whichever is applicable) to which I have made application for employment or to which I will make application for employment. By executing this form I release, discharge and hold harmless the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners and I/O Solutions, Inc. its directors, officers, staff, employees, agents, representatives, and assignees from any and all claims, demands, actions, fees and causes of action, suits at law, proceedings in equity, and liability that may arise by reason of the investigation into and the disclosure of my driving record. Agreed to:

_________________________________

Date_______________________

Applicant Name, printed

_________________________________

Date_______________________

Applicant Signature

_________________________________

Date_______________________

Witness Name, printed

_________________________________

Date_______________________

Witness Signature DO NOT SUBMIT WITHOUT OBTAINING A WITNESS SIGNATURE FROM AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE U.S.

Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 5 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.

MEDICAL RECORDS CONSENT I hereby consent for I/O Solutions, Inc., or its authorized representative to obtain my medical records from my primary physician for the period of time that my name appears on the Village of Hinsdale’s Final Eligibility List.

RELEASE

I understand that release of my medical records by this written authorization will result in disclosure of my medical records. I hereby consent to the release of my medical records to authorized representatives of the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners or to I/O Solutions, Inc. for appropriate review and/or dissemination to those municipalities and/or Police/Fire departments to which I have made application for employment or to which I will make application for employment. By executing this form I release, discharge and hold harmless the Village of Hinsdale, Hinsdale Board of Fire and Police Commissioners, and I/O Solutions, Inc., its directors, officers, staff, employees, agents, representatives, and assignees from any and all claims, demands, actions, fees and causes of action, suits at law, proceedings in equity, and liability that may arise by reason of the disclosure of my medical records as authorized herein by me. Agreed to:

_________________________________

Date_______________________

Applicant Name, printed

_________________________________

Date_______________________

Applicant Signature

_________________________________

Date_______________________

Witness Name, printed

_________________________________

Date_______________________

Witness Signature DO NOT SUBMIT WITHOUT OBTAINING A WITNESS SIGNATURE FROM AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE U.S.

Copyright 2010 by I/O Solutions, Inc.

HINSDALE FIRE DEPT. REQUIRED RELEASE DOCUMENT: PAGE 6 of 6

DO NOT SUBMIT WITHOUT OBTAINING WITNESS SIGNATURES OF AN ADULT FAMILY MEMBER OR FRIEND RESIDING WITHIN THE US. SEE CHECK LIST FOR LIST OF ALL REQUIRED DOCUMENTS DUE 12/06/2010. COPIES OR FAXES NOT ACCEPTED. INK SIGNATURES REQUIRED. CALL 800.343.HIRE WITH QUESTIONS.