Name
Date
Street Address
City, State, Zip
Email
Phone
What position are you applying for? Select One EMT Paramedic
If yes, when?
What Position?
If yes, who?
On what date would you be available for work?
If yes, please explain
If yes, please explain
Company 1
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Worked
Reason for leaving
Company 2
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Worked
Reason for leaving
Company 3
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Worked
Reason for leaving
If so, by whom and for what reason?
High School
Address
From
To
College
Address
From
To
Degree:
Other
Address
From
To
Degree:
Please list any licenses, registrations or certificates.
Please summarize special skills, qualifications or training you have acquired related to this job.
Branch
From --- To
Rank at Discharge
Type of Discharge
If other than honorable, explain
ADDITIONAL INFORMATION Use this space to describe you interests and/or accomplishments that you think qualify you for a position with the Company. Please remember we are an Equal Employment Opportunity employer and are not interested in receiving comments concerning religious or political activities or interests. If listing any organizations of which you are affiliated, exclude names and characters, which indicate race, color, religion or national origin of its members. Use additional pages if necessary.
Reference 1: Full Name
Relationship
Company
Phone
Address
Reference 2: Full Name
Relationship
Company
Phone
Address
Reference 3: Full Name
Relationship
Company
Phone
Address
In connection with my application for employment with Richmond Lenox EMS Ambulance Authority, I hereby authorize Richmond Lenox EMS Ambulance Authority, or its agents, to investigate my past employment and to verify the activities and statements contained in this application, my resume, or other documents, that I have submitted to Richmond Lenox EMS Ambulance Authority. I agree to fully cooperate with Richmond Lenox EMS Ambulance Authority in any such investigation. I hereby release all persons, educational institutions, law enforcement organizations, firms or corporations providing Richmond Lenox EMS Ambulance Authority with information pursuant to its investigation and verification from any and all liability or responsibility in connection therewith and I am specifically aware that such investigation may include obtaining my driving record if driving is a job requirement. If offered employment, I have no objection, if requested, to signing an employee agreement on confidential information, making application for a bond or security clearance, or taking a medical examination which could include a drug screen. In consideration of my employment, if I become employed, I agree to conform to the policies, procedures, rules and regulations of Richmond Lenox EMS Ambulance Authority. I understand and agree that my employment is at will and that my employment and compensation may (regardless of the time and manner of payment of my wages and salary) be terminated, with or without cause, and with or without notice, at any time by Richmond Lenox EMS Ambulance Authority or myself. I understand that no representative of Richmond Lenox EMS Ambulance Authority, other than the Chief of Richmond Lenox EMS Ambulance Authority, has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, and then only in writing, signed by myself and the Chief at the option of either Richmond Lenox EMS Ambulance Authority or myself. I agree that any claims or suits that I may have against the Company, its owners, members, officers, employees, representatives or agents arising out of my application for employment, employment or termination from 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 discrimination claims requiring a Notice of Right to Sue from the Equal Employment Opportunity Commission (“EEOC”), within ninety (90) days after the EEOC issues that Notice; or (b) for all other claims, within (i) one hundred eighty (180) days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I knowingly and voluntarily waive any limitation periods that exceed this time limit. I affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge, and agree that misrepresentations, false information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.
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