CESD50 APPLICATION

EMPLOYEE APPLICATION

Please take your time and complete ALL fields marked with a (*). Double check your entries before pressing submit, as errors will prevent submission. See closing note at the bottom of this application.

Date of Application *

Month Day Year

Select All That Apply *

FIRE Firefighter Full- Time EMS Paramedic Part- Time Other EMT

Full Name *

First Name Middle Name Last Name Suffix

Birth Date *

Month Day Year

Social Security Number *

Are you a U.S. Citizen or do you have the right to work in the U.S.? *

Yes No

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

E-mail *

Have you ever been convicted of a felony? *

Yes No

If yes, please explain.

Please list any traffic citations and/or accidents you have been involved in during the past 5 years.

1.

Date

2.

Date

3.

Date

Name of High School *

Address (City/State) *

Did you graduate? *

Yes No

Graduation Date *

Month Day Year

Degree Received *

Name of College *

Address (City/State) *

Did you graduate? *

Yes No

Graduation (or expected) Date *

Month Day Year

Degree Received *

Name of College

Address (City/State)

Did you graduate?

Yes No

Graduation (or expected) Date

Month Day Year

Degree Received

Please detail your work history for the last 10 years. Begin with your current or most recent employer. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation "See Resume." PLEASE NOTE: Harris County ESD No. 50 reserves the right to contact all current and former employers for reference information.

[Entry 1]

Organization Name *

Address *

Phone Number

Area Code Phone Number

Title *

Ending Salary *

Shift *

Full- Time Part- Time

Date Employed From *

Month Day Year

Date Employed To *

Month Day Year

Primary Duties *

Supervisor's Name, Title, and Contact Number *

Reason For Leaving *

Contact This Reference *

[Entry 2]

Organization Name

Address

Date Employed From

Month Day Year

Date Employed To

Month Day Year

Title

Ending Salary

Shift

Full- Time Part- Time

Primary Duties

Supervisor's Name, Title, and Contact Number

Reason For Leaving

Contact This Reference

[Entry 3]

Organization Name

Address

Date Employed From

Month Day Year

Date Employed To

Month Day Year

Title

Ending Salary

Shift

Full- Time Part- Time

Primary Duties

Supervisor's Name, Title, and Contact Number

Reason For Leaving

Contact This Reference

[Entry 4]

Organization Name

Address

Date Employed From

Month Day Year

Date Employed To

Month Day Year

Title

Ending Salary

Shift

Full- Time Part- Time

Primary Duties

Supervisor's Name, Title, and Contact Number

Reason For Leaving

Contact This Reference

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Relationship *

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Relationship *

Please scan and provide digital copies of the following documents (if applicable to the position to which you are applying.) We do prefer .PDF, however other acceptible formats include (.JPG, .PNG, .BMP).

Resumé

EMS Certification

TCFP Certification

Texas Driver's License

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Harris County Emergency Service District No. 50 to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and driving background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Harris County ESD No. 50 serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States. If selected for a paid position, I understand if that I would be required to make mandatory contributions to the Texas County & District Retirement System and TML medical. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice.

Signature *

Clear

Full Name *

First Name Last Name

AUTHORIZATION FOR BACKGROUND CHECK

(Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.)

I hereby authorize Harris County Emergency Service District No. 50 to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Harris County Emergency Service District No. 50 will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

Signature *

Clear

Full Name *

First Name Last Name

Note to applicant:

Be patient as the web-app is designed to "LOCK-UP" when you press SUBMIT to analyze the form for errors. This is to ensure the applicant does not make unwanted changes during analysis. Please DO NOT refresh or close the page!! Once the web-app has completed its analysis you will be able to scroll back through the application to complete the "red highlighted" error fields. Complete the errors then return to the bottom of the page. Press SUBMIT again and be patient while your application is analyzed again, or is submitted. Once completed, a "Thank You" screen will appear.

By clicking SUBMIT, you agree that you have completed the above information to the best of your abilities, and are ready to submit the application and background check authorization forms. You further acknowldge that your submission may be viewed by other (Channelview Emergency Service Disctrict 50) administrative staff acting as intermediaries between the form submission and the human resources department.

If you desire to PRINT a copy, please feel free to do so before pressing SUBMIT, as you will not have the option once the form has been submitted.

Submission Terms *

I Agree

Channelview Emergency Service Disctrict 50

Position

Personal Information

Education

Work Experience

Emergency Contacts

Additional Items Requested

Legal Understanding

Authorization

Submission