Job Application for ACEMS

Employment Application

Please complete the form below to apply for a position with us.
Please complete all documentation to the best of your ability. Applications that are not complete may not be considered for employment. All fields marked with a red star* are required to be completed to submit your application.

If you have any questions, please call Station 100 (937) 587-3598; option 1 or please call Captain Thomas W. Hook (740) 352-4965.

Adams County EMS is an Equal Opportunity Employer and reserves the right to accept or reject any applications.

Applicant Demographic Information:

Please provide the following information
Full Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Format: (000) 000-0000.

Education, Prior Employment, & Professional References:
YesNo

Education*

Rows	School	Location	Years Attended	Certificate/Degree Received	Major
High School/ GED
College
Technical School
Other
Other

Other Relevant Education, Certification, or Skills?
Please enter any skills or education you believe are relevant

Employment History:*

Rows	Employer	Job Title	Address	Phone Number	Supervisor	Dates Employed	Duties Performed
1
2
3
4
5
7

If there are any employers listed above you do not want us to contact, please explain

Professional References (please do not list family members):*

Rows	Name	Phone Number	Occupation	Years Known
1
2
3

PHYSICAL STATEMENT:
All applicants/personnel applying for a position with Adams County EMS are required to have a physical exam conducted by the practitioner designated by Adams County. All applicants must comply with this requirement, which demonstrates their capabilities to perform required job duties. If the applicant/personnel cannot display the capabilities required, they will not be eligible for employment. This must be completed to be eligible for the application process. All applicants/personnel must be physically able to perform the duties of the job for which you are applying. Those duties include, but are not limited to: lifting, twisting, bending, squatting, etc.
YesNo
YesNo
Signature*

Clear
Date*

MonthDayYear
Date

Applicant Statement:

Please read and sign the following:
1. I certify that facts contained in this application are true and complete to the best of my knowledge. I hereby authorize you to investigate of all statements, written and oral, made by me during the employment application process. I release all parties from any liability in connection with the provision and use of such information.

2. I understand and agree that any falsification, misrepresentation, or omission either on the employment application form, or in my responses to questions asked during the interview or examination process may disqualify me from further consideration for employment, or if employed, will subject me to immediate termination whenever the falsification, misrepresentation, or omission is discovered. In this regard, if an item is left blank on the employment application, it is because there is no information within its scope.

3. I understand and agree that, if employed by this organization, I will abide by its rules and regulations, which I understand are subject to change.

4. I understand that a physical examination and a chemical test for the present of illegal and controlled substances may be required before the commencement of and/or during my employment. I release Adams County EMS, their authorized agents, and their employees, and all other persons, companies and other entities from all liability arising out of any physical examination or chemical testing or for the taking of any action based on the results of any physical examination, or chemical testing.

I understand that, as a condition of my employment, I will be required to undergo a background investigation, driver's license check, drug testing, and a physical examination. My signature authorizes such to be conducted. I also understand and will comply with the physical and applicant statement, and adhere all information provided to be true, to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
Are you authorized to work legally in the US without restriction?
Are you able to provide proof of your eligibility to work?
Have you ever been discharged from a job?
Have you ever been convicted of a felony?
Are you willing to submit to a pre-employment drug test and background check?

Employment Application

Applicant Demographic Information:

Employment Questionnaire:

Education, Prior Employment, & Professional References:

PHYSICAL STATEMENT:

Certification(s)/Licensure(s):

Applicant Statement: