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*

	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

Unable to continue*
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*

Current, MORE than 10yearsCurrent, LESS than 10 YearsNon-Pennsylvania Resident
Primary Phone Number*
Please enter a valid phone number.
Primary Number Type*
Alternate Phone Number
Please enter a valid phone number.
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

C3 Health may contact me via text and Email
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*

Employment History / References
Upload Resume (select all that apply)

Includes at least three(3) Previous EmployersIncludes at least Three(3) ReferencesIncludes Educational Background
File Upload

You may upload a PDF Resume
Cancelof
Employer (1)*
Employer (2)*
Employer (3)*
Reference (1)*
Reference (2)*
Reference (3)*

Education*

Certifications
Guidance for taking pictures of Identification Cards and Certifications
State Issued ID*

Driver's LicenseID Only
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?*

YesNo
Certification Number*
Include State abbreviation Example: PA12345678
Exp. Date*

MonthDayYear
Date
Additional Add-ons

EMSVOEMS Instructor
Additional Physician Add-ons

Medical Command Physician
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?*

YesNo
Explain Criminal History
Have you had in the past 5 years any moving violations or had your driver's license suspended/revoked?*

YesNo
Explain Driving History
Have you ever had a professional license or certification suspended/revoked?*

YesNo
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*

Clear
Should be Empty:

Demographics