Employment Application

Comprehensive - Compassionate - HealthCare
Employment Application

C3 Health LLC is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other legally protected status. C3 Health LLC is a Drug Free Workplace
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Pre Application Questions

Rows	Yes	No
Are you over 16 years old?
Are you able to lift 150lbs or more?
Are you willing to perform all job duties as set forth by the Pennsylvania Department of Health Regulations/Standard/Protocols?
Do you consent to C3 Health LLC conducting background checks including, but not limited to, criminal history, driving history, employment, training/certification and references.
Are you legally allowed to work in the US

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If you feel you have reached this in error you may email ben@c3.health
Position Type
Certification
Days interested in working
Evenings interested in working
Overnights interested in working

Demographics
Name

PrefixFirst NameMiddle NameLast NameSuffix
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Pennsylvania Resident
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Number Type
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Number Type
As part of the employment process and during employment, C3 Health utilizes text messages and email for scheduling notifications and reminders. To help this process, we kindly ask for your permission to send text messages
Warning: NO Mobile Number Selected
Mobile Carrier
Consent to send Messages
Email
example@example.com
Today

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Age
To comply with insurance regulations, if you are hired, we must document the following: "Gender for Insurance and Compliance" and "Pronouns."

C3 Health, LLC does not set the choices for the following two(2) questions. Limits or inclusion of choices for these questions do not constitute any statements or beliefs, implied or otherwise, by C3 Health or its employees.
Gender for Insurance and Compliance
Pronouns

Education

Certifications
Guidance for taking pictures of Identification Cards and Certifications
State Issued ID
Restrictions
Select All that apply
State ID Number
Include State abbreviation Example: PA12345678
Exp. Date

MonthDayYear
Date
State ID Photo Upload (Front)

Cancelof
State ID Photo Upload (Back)

Cancelof
EMS Certification
National Registry?
Certification Number
Include State abbreviation Example: PA12345678
Exp. Date

MonthDayYear
Date
Additional Add-ons
Additional Physician Add-ons
EMS Cert Photo Upload (Front)

EMSVO Candidates Upload and EVOC Certificate in place of your EMS CERT
Cancelof
EMS Cert Photo Upload (Back)

Cancelof
CPR Expiration Date

MonthDayYear
Date
CPR Card Photo Upload (Front)

Cancelof
CPR Card Photo Upload (Back)

Cancelof
ACLS Expiration Date

MonthDayYear
Date
ACLS Card Photo Upload (Front)

Cancelof
ACLS Card Photo Upload (Back)

Cancelof
PALS Expiration Date

MonthDayYear
Date
PALS Card Photo Upload (Front)

Cancelof
PALS Card Photo Upload (Back)

Cancelof

Required Questions
Please upload copies of recent background checks. If you do not have copies, please get them at the links below:

Pennsylvania State Police Background Check

https://www.pa.gov/services/psp/request-a-criminal-history-background-check

Child Abuse History Certification (CY113)

https://www.pa.gov/agencies/dhs/resources/keep-kids-safe/child-abuse-clearances/pa-child-abuse-history-clearance
Pennsylvania State Police Background Check Date

MonthDayYear
Date must be within the last 2 years
Pennsylvania State Police Background Check

Cancelof
Child Abuse History Certification Date

MonthDayYear
Date must be within the last 5 years
Child Abuse History Certification (CY113)

Must be within the last 5 years
Cancelof
Have you ever been convicted, plead guilty or no contest to a felony or misdemeanor, including DWI/DUI?
Explain Criminal History
Have you had in the past 5 years any moving violations or had your driver's license suspended/revoked?
Explain Driving History
Have you ever had a professional license or certification suspended/revoked?
Explain Certification History

Certification of Accurate and Complete Application

I, {name}, certify that the information I provided to C3 Health in this application is true, accurate, and complete to the best of my ability. I understand that false information or omission may disqualify me from acceptance or result in dismissal from C3 Health LLC. Furthermore, my signature below implies my consent to C3 Health LLC conducting background checks, including, but not limited to, criminal history, driving history, employment, training/certification, and references.
Signature
Should be Empty:

Demographics