EMT Online Application – Harris Township Ohio

The Harris- Elmore Fire Department/ EMS Division
Application for Part- Time Employment

All fields must be completed accurately in order to be considered for employment. You may also upload a cover letter and resume (optional), however the application must still be completed.

Position Applying.

Position applied for^*

Personal Information

First Name^*

Middle Name^*

Last Name^*

Address

Address Line 1 ^*

Address Line 2

City ^*

State or Region ^*

Country ^*

ZIP ^*

Email^*

Enter email again^*

Phone^*

Driving History

Do you have a valid State of Ohio Driver License?^*

Do you hold a Driver License in any other State.^*

Has your Driver License ever been suspended or revoked?^*

Have you been involved in any traffic accidents where you were cited?^*

Drivers Explanation.

EMPLOYMENT ELIGIBILITY

Are you legally eligible to work in USA?^*

What is your notice period with your current company?

Current Ohio EMS Education and Training

Current Level of Certification:^*

Ohio Certificate Number:

Exp. at Current Certificate:

Check All Additional Credentials Held. You must currently hold an EMT, EMT-Advanced, or Paramedic, and CPR credentials in order to be considered. Provide copies of your certificates (front of the certificate).

CPR Certificate

CPR / Expires

CPR Certificate Front:

Firefighter Certificate

Firefighter Certificate / Expires:

Current Level of Certification:

Firefighter Certificate Front:

ACLS Certificate

ACLS / Expires:

ACLS Certificate Front:

National Registry Certificate

National Registry / Expires:

NR Certificate Front:

PALS Certificate

PALS / Expires:

PALS Certificate Front:

HazMat Certificate

HazMat / Expires:

Current Level of Certification:

HazMat Certificate Front:

Emergency Vehicle Operations Certificate

Date Issued

EVOC Certificate Front:

NIMS Certification

Current Level of Certification:

NIMS Certificate Front:

Formal Education

High School

State, City

High School Major/Minor:

Graduate?

College/University

State, City

College Major/Minor:

College Degree Earned:

Collage Grad?

Other

State, City

Year of completion

Degree/Certifications:

Graduate?

EMPLOYMENT HISTORY

EXPERIENCE: Please provide a complete record of your employment, beginning with your present or most recent employer. Account for all periods in the last seven years, including self-employment and unemployment.

Current employer (company/Individual)

Employer Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Employer Phone

Supervisors Name

Start Date

End Date

Reason for Leaving:

May we contact for a reference?

Job responsibilities

Previous Employment

Previous Employer

Previous Employer Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Previous Employer Phone

Previous Supervisors Name

Start Date

End Date

Reason for Leaving:

May we contact for a reference?

Job responsibilities

Previous 2 Employment

Previous employer 2

Previous 2 Employer Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Previous 2 Employer Phone

Supervisors Name

Start Date

End Date

Previous Reason for Leaving:

May we contact for a reference?

Job responsibilities

Additional Employment History

REFRENCES

Your reference within this company

Employee ID

REFERENCES: (EXCLUDING RELATIVES AND PREVIOUS EMPLOYERS)

Reference 1

First Name (ref1)

Last Name (ref1)

Address (ref1)

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Phone (ref1)

Relationship (ref1)

Reference 2

First Name (ref2)

Last Name (ref2)

Address (ref2)

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Phone (ref2)

Relationship (ref2)

Reference 3

First Name (ref3)

Last Name (ref3)

Address (ref3)

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Phone (ref3)

Relationship (ref3)

SUPPORTING DOCUMENTS

Cover Letter, Resume, & References

Disclaimer^*

I certify that all information provided herein is true and complete to the best of my knowledge. I hereby authorize Harris- Elmore Fire Department/ EMS Division and the Harris Township Trustees to make any investigations of my criminal, motor vehicle, education, and employment histories or any other related affairs as maybe necessary in arriving at an employment decision. I also release all persons from liabilities in responding to inquiries regarding my application. In the event of employment, I understand that upon discovery of false or misleading information in my application or during my employment interview, may result in my discharge. I also understand that I am required to follow all rules, regulations, policies, procedures, and job requirements of Harris- Elmore Fire Department/ EMS Division and that failure to do so may result in discharge.

I accept