CCEMS Employment Application Form

Colorado County Employment Application
Name:*

First NameMiddle InitialLast NameSuffix
Other Names by which you have been known (if any)

First NameMiddle InitialLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Birth Date

MonthDayYear
Social Security Number
Home Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
E-mail Address:*
Emergency Contact*

NamePhoneE-Mail
Position Desired*

ParamedicAEMTEMT
Current Certification*

EMTAEMTParamedic
License Information*

License NumberInitial Date of CertificationDate of Expiration
Relatives Currently or Formerly Employed at Company
First NameMiddle InitialLast Name
First NameMiddle InitialLast Name

Education & Employment History

Start with your current or most recent employer and work backwards regarding all former employers.
Education
High School Name*
High School Address*
High School Information

Years CompletedGraduation YearGED (Yes/No)
College/University Name*
College/University Address
College/University Information

Years CompletedGraduation YearDegree Awarded (Yes/No)
Specialized Training or Trade School Information (#1)

NameDegree/CertificationYear completed
Specialized Training or Trade School Information (#2)

NameDegree/CertificationYear completed
Specialized Training or Trade School Information (#3)

NameDegree/CertificationYear completed
Employment
Current or Most Recent Employer:*
Name of Employer
Employer Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of Employment

Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week/Reason for Leaving

Hours worked per Week Reason for Leaving
May we Contact this Employer?*
Next Recent Employer: (#2)
Name of Employer
Address of Employer #2
Address
City, State, Zip #2
Last Position You Held (#2):
Immediate Supervisor(s) (#2)
Immediate Supervisor(s)
Employer Phone Number (#2)
Phone Number(s)
Employer Date and recent salary (#2)

Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities (#2)
Job Title and Responsibilities
Hours per week and reason for leaving (#2)

Hours worked per Week Reason for Leaving
May we Contact this Employer?
Military Information

Branch of ServiceYears of ServiceRank at Discharge
Honorable Discharge?
Military Reserve Information

Are you in the US Military Reserves? (YES/NO)Years of ServiceAre you Active? (YES/NO)
National Guard Information

Are you a member of the National Guard? (YES/NO)Years of ServiceAre you Active? (YES/NO)
References

Please list two references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please indicate the relationship this person has to you:
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please indicate the relationship this person has to you:

Employment Screening
1. Can you provide proof of eligibility to become employed in the United States?*
If no on #1, are you able to provide such proof which will be required upon employment if you are offered a position?
2. If you are under the age of 18, can you provide required proof of your eligibility to work?*
3. Have you ever filed an application for employment with us before?*
4. Are you currently employed?*
5. Are you currently on layoff status and subject to recall?*
6. Do you have adequate transportation to meet travel requirements of the job?*
7. Do you have a current valid drivers license?*
Driver's License Information

Issuing StateExpiration Date
8. Are you able and willing to travel for this job if travel is necessary?*
9. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
If yes, please provide a reason below
10. Have you ever been terminated or forced to resign from your employment with any employer?*
If yes, please provide a reason below:
11. Have you ever been denied a security clearance?*
If yes, please explain including the employer for whom the security clearance was denied, the date on which such security clearance was denied and the reason that such security clearance was denied:
If yes, please provide a reason below:
12. Have you ever been convicted of a crime including any driving and/or alcohol related offenses?*
If yes, please explain:
If yes, please provide a reason below:
13. Are you interested in Part-Time or Full Time?*

Company Policies
I authorize Colorado County EMS to make any inquiries they desire regarding my education, employment, ability, habits and personal character for the purpose of determining my fitness for employment. I also authorize previous employers or any other persons to whom this may refer to give any and all information
regarding my employment or scholastic record together with any information, personal or otherwise , and I hereby release such persons and any companies which they represent from all liability or any damages whatsoever in connection with their compliance. I understand that misrepresentation or omission of any fact or circumstance called for in this application which would affect my application unfavorably or receipt of unsatisfactory references, will be sufficient course for termination without liability to me for salary except as may have been earned at the time of my termination.

By Submitting this application I understand that the Company requires its employees to adhere to the highest standards of business and personal ethics and responsibility. I understand that the Company believes that one method by which such high standards are demonstrated is through the timely meeting of financial obligations. Consequently, I understand and agree that by making application for a position with this company, I am agreeing that my credit worthiness is substantially related to the job for which I am applying or which I hold and that my credit worthiness may be examined by the company. I further understand and agree that this application is not a contract of employment.

I understand and agree that the Company adhere to a policy of employment at will which means that either I, or the employer, may terminate my employment at any time, or for any reason, consistent with application of state and federal law. I further understand that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is in a written employment contract naming me and signed by the President of the Company. I understand that to be employed, I must be lawfully authorized to work in the United States and must show the employer documents to prove this. I understand that the Company may investigate my work and personal history and verify the information provided in this application, on related documents or information obtained through other sources and I hereby authorize such investigation. I authorize all individuals, schools, firms and business named in this application or in other documents or interviews, except my current employer if I have so designated in this application, to provide complete and accurate information regarding my relationship with them to the Company.

I further release those individuals, schools, firms and business and the Company from any and all liability for damage for providing or requesting such information. I certify under penalty of perjury that all of the information provided in the entire application process including any information provided in addition to this application including, but not limited to, information provided in resumes or interviews is true and correct. I understand that if there is any falsification or omission, this may lead to the Company’s refusal to hire me or a determination, at any time, that my employment should be terminated.

The Company is an Equal Employment Opportunity Employer and considers all applicants without regard to race, color, religion, gender, national origin, age, marital status, veteran’s status, the presence of a mental, physical or sensory disability, sexual orientation, or any other legally protected status. Employment shall be based solely on the needs of the companies and the qualifications of the individuals making application.
By completing this application, you understand and accept that you are applying for a position as an "At Will" employee. "At Will" employment means that either you or the Company can terminate your employment with or without cause and with or without notice.
You must accept all Company Policies to proceed with the application process

I accept these Policies
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

Colorado County Employment Application

Relatives Currently or Formerly Employed at Company

Education & Employment History

Education

Employment

References

Reference 1

Reference 2

Employment Screening

Company Policies

By completing this application, you understand and accept that you are applying for a position as an "At Will" employee. "At Will" employment means that either you or the Company can terminate your employment with or without cause and with or without notice.