EMPLOYMENT APPLICATION

Date of Application

Name (Last, First, Middle):

Position applying for:

Are you applying for Full or PRN Employment:

For Billing or Dispatcher applications, are you 18 or older?

Our current insurance requires all operators of our emergency vehicles to be 18 years of age or older.

If you are applying for an EMS field position, are you 18 or older?

If you are applying for EMS field position, you must possess the following licenses/certifications to be eligible for employment.

Do you posses a valid Driver’s License?

YES NO

Do you posess a current BLS Healthcare Provider Card?

YES NO

Do you possess current State of Oklahoma and NREMT licenses-Unless exempt from NREMT by Statute?

YES NO

Have you completed NIMS 100?

YES NO

Have you completed NIMS 200?

YES NO

Have you completed NIMS 700?

YES NO

Have you completed NIMS 800?

YES NO

If you are applying for EMT-PARAMEDIC, are you ACLS Certified?

YES NO

If you are applying for EMT-PARAMEDIC, are you PALS Certified?

YES NO

General Questionnaire and Legal Notice

If you answer NO to any question below, you will not be eligible for employment.

A pre-employment drug screening, at no cost to you, is required. Do you consent?

YES NO

A pre-employment physical agility test, at no cost to you, is required. Do you consent?

YES NO

Pre-employment background checks, at no cost to you, including, but not limited to: A Criminal Background Check, Court Record Check, and a Credit Screening. Do you consent?

YES NO

Regular and random drug, and if deemed necessary by administration, alcohol screening at no cost to you. Do you consent to Drug and or Alcohol screening?

YES NO

PICTURE RELEASE: CCEASD often interviews numerous applicants. It can be difficult for us to remember candidates and accurately place a person with their application and interview notes. To aid us with this, we obtain a photograph of candidates prior to the interview. YOU DO NOT HAVE TO CONSENT to this photograph. If you consent, check “yes”. If you do NOT, check “no”.

YES NO

LEGAL NOTICE: Creek County Ambulance provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic prohibited by federal, state or local laws.

This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer; leaves of absence, compensation and training.

Demographics

Legal Name (Last, First, Middle):

Social Security Number:

Driver’s License Number and Issuing State:

Primary Contact Number:

Contact Email:

Alias/Past Name (Last, First, Middle):

Current Address:

Were or are you a current member of the United States Military?

YES NO VETERAN

If you answered YES, Please select your Branch:

If you answered YES, Please attach copy of DD214

Choose a file

Max. size: 64.0 MB

MOS, AFSC or NOSC:

If Discharged, type of Discharge:

Have you been CONVICTED, PLED GUILTY, or ‘NO CONTEST’ to a FELONY CHARGE?

YES NO

If you answered YES to the above question, please explain in detail:

Have you been CONVICTED, PLED GUILTY or ‘NO CONTEST’ to any Violent Crime, and or Sexual Related crime or the intent or conspiracy to commit such crime(s)?

YES NO

If you answered YES to the above question, please explain in detail:

Have you been CONVICTED, PLED GUILTY or ‘NO CONTEST’ to a MISDEMEANOR? Including any TRAFFIC CITATIONS/MOVING VIOLATIONS within the last seven (7) years?

YES NO

If you answered YES to the above question, please explain in detail:

Are you currently under a DEFERRED PROSECUTION or DEFERRED SENTENCING AGREEMENT?

YES NO

If you answered YES to the above question, please explain in detail:

Education History

Name of Institution:

City and State:

Primary Area of Study:

Start Month-Year to End Month Year:

Degree of Certification Issued:

Name of Institution:

City and State:

Primary Area of Study:

Start Month-Year to End Month-Year

Degree or Certification Issued:

Name of Institution:

City and State:

Primary Area of Study:

Start Month-Year to End Month-Year

Degree or Certification Issued:

Licenses and or Certifications

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

License/Certification and Number (If Applicable):

Issued By:

Expiration Date:

Employment History

Present or Last Employer:

City, State:

Title:

Start Month-Year to End Month-Year:

Wage:

Direct Supervisor:

HR Contact:

HR Telephone Number:

May we contact this employer?

YES NO

Continued Employment History

Previous Employer:

City, State:

Title:

Start Month-Year to End Month-Year

Wage:

Direct Supervisor:

HR Contact:

HR Telephone:

May we contact this employer?

YES NO

Continued Employment History

Previous Employer:

City and State:

Title:

Start Month-Year to End Month-Year

Wage:

Direct Supervisor:

HR Contact:

HR Telephone Number:

Can we contact this employer?

YES NO

Personal References

Name:

Telephone Number:

Name:

Telephone Number:

Name:

Telephone Number:

Professional References

Name:

Telephone Number:

Name:

Telephone Number:

Name:

Telephone Number:

Additional Questions

Were you referred by any employee of Creek County Ambulance?

YES NO

Who referred you to Creek County Ambulance?

Oklahoma has a nepotism law that prohibits hiring any person who is related by blood or marriage to the third degree to a public official. Do you have any relatives who are currently employed by this company or who currently serve on the board of directors for this company?

YES NO

Please list employees or board members:

I, the undersigned, understand that Creek County Ambulance is an at-will employer and that I have read and acknowledge the job decsription and minimum requirements page prior to completing this employment application, is not an employment agreement or contract. I also understand that the information provided in this description is designed to indicate the general nature and level of work performed for this position and that it is not to be interpreted as a comprehensive inventory of all duties, responsibilities, qualifications, and or working conditions required of this position.

YES NO

Electronic Signature:

Date Electronically Signed:

PLEASE READ CAREFULLY: In accordance with the Americans with Disabilities Act, Creek County Ambulance will provide reasonable accommodations to the known disabilities of applicants and employees, unless to do so would pose an undue hardship as an employer. Please fill free to let us know if you need any accommodations to complete this application process or to perform any essential elements of the position sought. Applicants are considered for all positions, and staff members are treated fairly during their time of service, without regard to race, color, religion, sex, national origin, marital status, age, disability, veteran status, or any other prohibited basis of discrimination, as provided under applicable local, state, and federal law.

Creek County Ambulance is an “at-will” organization, which means the employee may resign at any time and the employer may discharge the employee at any time for any reason with or without cause. This “at-will” relationship may not be changed by a verbal agreement, written document or by conduct unless such change is specifically acknowledged by the current Director of Creek County Ambulance. When processing this application, Creek County Ambulance may request a Criminal, General or Credit background check on you for the sole purpose of employment consideration. Additionally Creek County Ambulance may contact past employers, supervisors, and/or any other person listed in this application regarding the statements made herein and your suitability for employment. This inquiry may include information as to your general character, reputation, and work-related characteristics. You have the right to make a written request to administration of this organization to disclose to you the content of these reports.

Applicants that have been offered an employment opportunity will be required to take and test negative to a DOT “drug screen” before employment begins. “Drug screens” will be organized and sponsored at a healthcare facility of Creek County Ambulance’s choosing. Excluding dispatch and office staff. applicants who have been offered an employment opportunity will be required to take a DOT physical and receive an unrestricted “qualification” card before employment begins. DOT physicals will be organized and sponsored at a healthcare facility of Creek County Ambulance’s choosing. Excluding dispatch and office staff. applicants who have been offered an employment opportunity will be required to take and successfully pass a Human Performance Evaluation before employment begins. Human Performance Evaluations will be organized and sponsored at a healthcare facility of Creek County Ambulance’s choosing.

This application will remain on file for a period of 18 months. Any applicant wishing to be considered for employment beyond that time must fill out a new employment application.

Resume

Choose a file

Max. size: 64.0 MB

By electronically signing your name, you certify that all statements made by you on this application are TRUE and COMPLETE to the best of your knowledge, and that any misrepresentations or omissions by you, may be cause for rejection of your application, or may be cause for subsequent dismissal if you are hired.

Creek County Ambulance – In Service For Life!