EMT Certification Application

Choctaw County Ambulance Authority
STUDENT CLASSROOM APPLICATION
Please Answer All Questions. Resumes Are Not A Substitute For A Completed Application

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, sexual orientation, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws.

THE CHOCTAW COUNTY AMBULANCE AUTHORITY (CCAA) IS AN AT-WILL EMPLOYER/EDUCATOR AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF ACCEPTED, THE TRUST OR I MAY TERMINATE THE EDUCATIONAL RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.
Name*

First NameLast Name
Date

MonthDayYear
Date
Street Address
City
State
ZIP Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security No*
DOB*
Have you previously applied for training with CCAA?*

YesNo
If Yes when and where did you apply
Have you ever been employed by CCAA?*

YesNo
If yes, provide dates of employment, location and reason for separation from employment.
If applicable below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record Example change of name use of an assumed name nickname etc
2578 US 70 BYPASS, HUGO, OK 74743

580-326-2634
Choctaw County Ambulance Authority

EDUCATION
High School
Address
Did you graduate?*

YesNo
From-To:
Diploma
College
COLLEGE:
Address
From-To:
Degree
Did you graduate?*

YesNo
Other
Address
Did you graduate?

YesNo
From-To:
Degree
Military Service
Branch
From-To:
Rank at Discharge
Type of Discharge
If other than honorable explain
Please list three professional references.
Full Name*
Company*
Relationship
Phone*
Address
Company*
Full Name*
Relationship
Phone*
Address
Full Name*
Company*
Relationship
Phone*
Address
Choctaw County Ambulance Authority

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I authorize CCAA or its agents to confirm all statements contained in this application and/or resume as it relates to the training, I am seeking to the extent permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding CCAA's intent to obtain "consumer reports." Iauthorize and consent to, without reservation, any party or agency contacted by CCAA to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to CCAA or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which | may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability CCAA and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, | authorize CCAA to provide truthful information concerning my employment to future employers and hold CCAA harmless for providing such information.

If accepted into training program offered by CCAA, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by CCAA. I also understand CCAA employs only individuals who are legally eligible to work in the United States.

| CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE AND COMPLETE.

DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
CONFIDENTIAL

Choctaw County Ambulance Authority
Background Check Authorization
First*
Middle*
Last*
Former names and dates used:
Current Address Since:
MoYr
Street
City
StateZip
Previous Address Since:
MoYr
Street
City
StateZip
MoYr
Street
City
StateZip
Social Security Number*
Telephone Number*
Drivers License NumberState*
State*
The information contained in this application is correct to the best of my knowledge. I hereby authorize Choctaw County Ambulance Authority, (CCAA) and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from an criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. Ifurther authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to CCAA or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation or public agency may have, to include information or data received from other sources. CCAA and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Choctaw County Ambulance Authority

STUDENT CLASSROOM APPLICATION

2578 US 70 BYPASS, HUGO, OK 74743

Choctaw County Ambulance Authority

College

Military Service

Please list three professional references.

Choctaw County Ambulance Authority

CONFIDENTIAL

Background Check Authorization

Current Address Since:

Previous Address Since: