Muskogee County EMS

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Application for Employment

An Equal Opportunity Employer.

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, or any other characteristic protected by applicable federal, state, or local law.

Application for Employment 2022

GENERAL INFORMATION

What position are you applying for?

Reaquired field: EMT Basic

Reaquired field: Advanced EMT

Reaquired field: Paramedic

Reaquired field: Emergency Medical Dispatcher (EMD)

Reaquired field: Other

First Name

Last Name

Best Phone Number to Contact You

Reaquired field: Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Availability

Can you perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

Can you provide proof of eligibility to work in the United States?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

Have you previously been employed with us?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If yes, please list dates of employment:

Employee Referral :

Availability

Date available to work

Are you looking for:

Reaquired field: No Answer

Reaquired field: Full-Time

Reaquired field: Part-Time

Would you prefer:

No Answer

Days

Nights

Weekends

Any

Hours Available:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Employment Experience

Employment Experience Start with your present or most recent employment. Include any job-related military service assignments and volunteer activities. You may exclude organizations which may indicate race, color, religion, gender, national origin, any disability or other protected status. This section must be completed in full, even if attaching a resume.

Current or Most Recent Employer

City, State

Job Title / Position

Supervisor Name & Phone Number

Duties

Reason for Leaving

Dates Employed

Salary

May we contact this employer?

No Answer

Yes

If the answer is no, briefly explain:

Previous Employment

Previous Employer

City, State

Job Title / Position

Supervisor Name and Phone Number

Duties

Reason for Leaving

Dates Employed

Salary

May we contact this employer?

No Answer

Yes

If the answer is no, briefly explain:

Previous Employer

City, State Copy

Job Title / Position:

Supervisor Name and Phone Number

Duties

Reason for Leaving

Dates Employed

Salary

May we contact this employer?

No Answer

Yes

If the answer is no, briefly explain:

Previous Employer

City, State

Job Title / Position:

Supervisor Name and Phone Number

Duties

Reason for Leaving

Dates Employed

Salary

May we contact this employer?

No Answer

Yes

If the answer is no, briefly explain:

Work History

Please explain any gaps in employment:

What did you like the most about your current and previous jobs?

What did you dislike about your current and previous jobs?

Have you ever been terminated (fired) or asked to resign employment?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If you answered Yes, please explain:

Have you applied here before?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If you answered Yes, please provide dates:

EDUCATION

High School Name:

City, State:

Did you graduate or receive your GED?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If no, highest grade completed?

College Name:

City, State:

Did you graduate?

No Answer

Yes

Course of Study?

Degree:

Other School Name

City, State:

Did you graduate?

No Answer

Yes

Course of Study?

Degree:

License / Certification Information

Do you hold any instructor licenses?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If yes, please list"

Has your professional license and/or certification ever been suspended or revoked?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If yes, please explain:

Have you ever been excluded or are you currently excluded from participating in any federal health program such as medicare or medicaid?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If yes, please explain:

TRAINING

Describe any specialized training, apprenticeships, job-related skills, or relevant extra-curricular activities. Include training received in the US military.

Office / Technical Skills -

For office or communications applicants only. Please check all that apply:

Keyboard

Excel

PowerPoint

Word

Other

Words Per Minute

References

Please provide three persons, not related to you, whom you have known at least one year. Please indicate individuals who can speak to your work performance.

Name:

Phone Number:

Years Acquainted:

Relationship:

Name:

Phone Number:

Years Acquainted:

Relationship:

Name:

Phone Number:

Years Acquainted:

Relationship:

Driving Record:

For field employees, maintenance, and other driving positions as detailed in the job description ONLY. The driving record of an applicant for these types of positions is relevant in determining past experience and qualifications.

Drivers License Number:

State

Expires:

Special Licenses & Endorsements (Please Specify)

Do you have 2 or more years of driving experience?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

Have you driven emergency equipment before?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

Have you ever had a license, permit, or privilege to operate a vehicle suspended, revoked, denied, or cancelled?

Reaquired field: No Answer

Reaquired field: Yes

Reaquired field: No

If yes, please explain:

MOVING VIOLATIONS for past three (3) years:

Date and Location:

Charge (If speeding, list MPH over limit):

Penalty:

Date and Location:

Charge (If speeding, list MPH over limit):

Penalty:

Date and Location:

Charge (If speeding, list MPH over limit):

Penalty:

ACCIDENTS for past three (3) years:

Date and Location:

Nature:

At fault?

No Answer

Yes

Date and Location:

Nature:

At fault?

No Answer

Yes

Date and Location:

Nature:

At fault?

No Answer

Yes

PLEASE READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT. 1. Certification of Truthfulness; I represent that all my statements in support of my Application for Employment are true and complete. I understand and agree that if EMPLOYER, at any time, should determine that any requested information was withheld by me or any of my statements are false or misleading, I may be discharged. 2. Employment at Will; If hired by EMPLOYER, I agree to comply with all rules, regulations, policies, and communications directed to employees, including any changes made from time to time. I understand that I will be free to resign my employment at any time with or without cause, and with or without prior notice or warning to EMPLOYER; I agree that EMPLOYER also may terminate my employment at any time, with or without cause and with or without prior review, notice, or warning. 3. Limitation on Claims: l agree that any lawsuit against EMPLOYER and/or its agents arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Right to Sue from the EEOC, within 90 days after the EEOC issues that Notice; Or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (il) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit. 4. Authorization to Work; If I am selected for hire, I will be offered employment provided I certify and produce applicable documentation that I am authorized to work as required by the Immigration Reform and Control Act of 1986. 5. Need For Accommodation; If I, due to a physical or mental disability, require an accommodation to perform the essential functions of the job for which I may be selected, I understand and agree that I will give EMPLOYER written notice of that need immediately after I know or reasonably should have known that an accommodation is needed. Failure to do so may bar me from alleging that EMPLOYER has not accommodated me as required by law. 6. Drug Testing: I agree to provide EMPLOYER with appropriate specimens to test for the presence of drugs or other controlled substances. I understand that decisions concerning my employment will be made as a result of these tests. 7. Physical Exam and Release of Medical Information; I understand that any job offer will be conditioned on passing a physical exam. I authorize every medical doctor, physician or other health care provider (HCP) to provide any and all information, including but not limited to medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I will cooperate in obtaining any additional authorization required by any HCP for release of any information. I hereby release every HCP and every other person, firm, officer, corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability for disclosure made pursuant to my authorization. I understand that medical information will not be requested from me, my physician or other HCP until a job offer has been made. 8. Disclosures; I agree that the contents of any offices, work spaces, desks, computer and computer generated data, any EMPLOYER property I may be using, and any of my own property I bring onto EMPLOYER's premises, may be inspected by EMPLOYER at any time it determines there is reasonable cause to do so, and I waive and promise not to make any claims against EMPLOYER (or its employees or agents) relating to such inspection. I agree that, except as directed otherwise in writing by EMPLOYER, I will not disclose to anyone or use for my own purposes, any of EMPLOYER's confidential or proprietary information, either during or after my employment. I understand and agree that client names and information, financial data, computer information and processes are confidential and proprietary information and I will not make written or other copies or notes regarding these matters except as necessary to perform my job. I agree that if my employment ends, I will deliver to EMPLOYER all material of any kind that I have relating to its business, including any such copies or notes. I agree that if any of the above commitments by me is ever found to be legally unenforceable as written, the particular agreement concemed shall be limited to allow its enforcement as far as legally possible. 9. Consideration for Employment: I agree to the above terms of employment if I am employed by EMPLOYER. Should I be employed, I understand and agree that these provisions of my employment can be revised only by a signed contract authorized by a written resolution of EMPLOYER, and that no person in EMPLOYER has any authority to offer employment other than on an at-will basis as described above. I understand and agree that, except as provided above, all compensation, benefits, programs, rules, and policies of EMPLOYER are subject to exception or change at any time as decided by EMPLOYER in its sole discretion. I acknowledge by my signature that I have been given adequate time to read, complete, and review my application and this certification, and I have knowingly and voluntarily signed below. If this application was completed in conjunction with an online Application for Employment, I acknowledge that my electronic signature is as valid as a traditional signature in accordance with the Fair Credit Reporting Act (F-CRA), the Electronic Signatures in Global and National Commerce Act (ESIGN), and FTC guidelines. I have read and understand the items listed in the Application for Employment, including this page, and acknowledge that with my signature below. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

By typing my FULL legal name, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Date:

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