Application for Employment

Positions Applied For: EMT-Basic EMT-Intermediate EMT-Paramedic Office Clerk Billing Specialist Other:
  RN            

First Name:
Middle:
Last:
Date of Birth (dd / mm / yy):
/ / 		Social Security No. (no dashes).:
 
Present Street Address:
City:
State:
Zip Code:

Telephone #:
- -

 
Legal / Voting Residence Address
 City:
State:
Zip Code:

Telephone #:
- -

 
Email Address:

Emergency Notification

Full Name:
Telephone #:
- - 		     
Address:
 City:
State:
Zip Code:
Relationship:
Have you filed an application here before? Yes No
    If yes, give date: / /
Have you ever been employed by this company? Yes No


 If so, why did you leave?
:

Are you employed now? Yes No
May we contact your present employer?
Yes No
 
Why do you desire to change?
 
Have you ever been forced or asked to resign from any position? Yes No If yes, by whom?
       
Explain:

Are you eighteen years of age? Yes No
Are you a U.S. citizen, or if not, do you have a legal right to work in this country?
Yes No
On what date would you be available to work? / /
 
Are you available to work: Full Time Part Time Temporary  

Are you on a layoff and subject to recall? Yes No
Can you travel if a job requires it?
Yes No
1.     If Conditionally selected for employment, would you be willing to take a physical examination if required? Yes No
     
2.     Is there any reason(s) which prevents you from adequately performing the essential functions of the job for which you are applying with or without reasonable accomodation? Yes No
     
3.     Have you ever been disciplined or discharged for excessive absenteeism? Yes No
     
4.     Have you ever been disciplined or discharged for violating a company rule or policy? Yes No
     
5.     Have you ever been disciplined or discharged for incidents regarding safety or excessive accidents? Yes No

6.     Have you ever been convicted of a felony? Yes No Date
/ / 		City
 State
           
7.     Have you ever been convicted of driving while intoxicated or driving under the influence of alcohol or drugs? Yes No Date
/ / 		City
 State

Education

Education
Name and Location of School
Years Attended
Year Graduated
Degree or Certificate Received?
High School
 to
Yes
No
Type:
College
 to
Yes
No
Type:
Trade, Business or Correspondence School
 to
Yes
No
Type:

Honors Received, Extra-Curricular Activities
     
US Military or Naval Service: Rank: Present Membership in National Gaurd or Reserves:
     
Special Training, Apprenticeship, or Skills (That would be of special benefit to the job for which you are applying)

Notice

All applicants conditionally selected for employment may be subject to a physical examination consisting of the following: complete physical examination, functional test and drug screen including marijuana detection.

Harris County Emergency Services District #1 Company and its affiliates (the “Company”) has a policy of maintaining a safe and healthy work environment for all its employees. This is to notify all applicants as potential Company employees that use or possession of illegal or unauthorized drugs, alcoholic beverages, firearms or weapons is not permitted in or on any of the Company’s Offices, vehicles, or other installations, and that the possession, use and/or distribution of any such items by any person in Company’s Offices, vehicles, or other installations owned or operated by the Company poses a serious threat to the safety of Company personnel and the Company’s operations.

As a means of enforcing this policy, the Company or the Company’s customers reserve the right to conduct searches or inspections (including complete medical examination, drug screen and marijuana detection) of employees, persons, personal effects and lockers for the purposes of determining if any employees have used, are using or are in possession of any such illegal or unauthorized items. Such searches may be made from time to time by authorized Company representatives without prior warning. The searches may be made of anyone entering or departing from any Company’s Offices, vehicles, or other installations (whether Company-owned or leased).

Refusal to submit to a search, inspection or examination of one’s person or property by any Company employee, or any Company employee found to have used, be using or be in the possession of any such illegal or unauthorized items will be cause for disciplinary action up to and including immediate discharge.

Any illegal items found as a result of searches by the Company will be taken into the custody of the Company and may be turned over to the proper law enforcement authorities.

Authorizations

I authorize investigation of all statements contained in this application. I hereby authorize the Company to conduct an investigative consumer report on me, as defined in Public Law 91-508, and/or the Fair Credit Reporting Act, and I understand that such a report may include information as to my character, general reputation, personal characteristics, crime history, financial condition, and mode of living. I understand that I may make a written request for the disclosure of the nature and scope of the investigation. I understand that misrepresentation or omission of fact called for herein or misrepresentation or omissions of fact provided the Company hereafter is cause for disciplinary action up to and including discharge. Further, I understand and agree that any employment which may result from this application is for no definite period, that no promise of continued employment is binding on the Company unless in writing and signed by the President of the Company and that I may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. If employed, I further hereby authorize the Company to make deductions from my salary, wages, or other compensation in connection with any valid child support order or garnishment order, as well as the repayment of any amounts I may owe the Company at any time during such employment.

I Understand and Agree to the Above Terms and Conditions


Harris County ESD #1 is an Equal Opportunity Employer

Applicant Data Record

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, pregnancy, age, citizenship status, veteran’s status, disability or any other characteristic protected by law.

As employers/government contractors, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

Affirmative Action Survey

Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntary.

Gender: Male Female

Race/Ethnic Group: White Black Hispanic American Indian/Alaskan Native Asian/Pacific Islander

Check if any of the following are applicable: Vietnam Era Veteran Disabled Veteran Handicapped Individual

Dates (dd/mm/yy)
Employer's Name and Address
Start: / /

End: / /

Employer:

Address:

Telephone #:
- -


Position Held:

Reason for Leaving:

Salary:
Start: / /

End: / /

Employer:

Address:

Telephone #:
- -


Position Held:

Reason for Leaving:

Salary:
Start: / /

End: / /

Employer:

Address:

Telephone #:
- -


Position Held:

Reason for Leaving:

Salary:
Start: / /

End: / /

Employer:

Address:

Telephone #:
- -


Position Held:

Reason for Leaving:

Salary:

References (other than relatives and former employers)
Name Address Home Phone Business Phone Years of Acquaintance
- - - -
- - - -
- - - -

Medical Certification Information

Certification
Number
State Issued
Issue Date (mmyyyy)
Expire Date (mmyyyy)
EMT-Basic
EMT Intermediate
EMT-Paramedic
BLS-CPR Card
ACLS-Provider
PALS
PPPC
AMLS-Provider
CEVO/EVOC
EMS-Instructor
EMS-Examiner
EMS-Coordinator
RN

Copies of all Certifications, Drivers License, Social Security Card must be attached to be considered for employment.

Authorization for Release of Personal Record Information

To whom it may concern:
* I have read the above “Notice to Applicants/Employees Regarding Consumer Reports” and hereby authorize the company to
obtain consumer reports and/or investigative consumer reports as described.
* I understand that I have the right to make a written request within a reasonable amount of time to receive additional, detailed
information about the nature and scope of any investigative report or other consumer reports that are made, including the name, address
and telephone number of the consumer reporting agency.
* I hereby authorize and request any present or former employer, school, police department, financial institution, division of motor
vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me to furnish bearer with any and all
information in their possession regarding me, in order that my employment qualifications may be evaluated. I hold said persons and/or
organizations blameless and without liability for statements or opinions made regarding my character, experience or qualifications I am
willing that a photocopy of this authorization be accepted with the same authority as the original.

I hereby acknowledge that I have read the above statement and have understood it.

Other Names Used (Including maiden, married, nickname, name change):
Used From:   / /    to     / /
 
Used From:   / /    to     / /

Current & Former Addresses (please start with current address; include dates of residence)
City, State, Zip/ Number & Street
Start Date
End Date
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /

Driver License No: State:

**Please List Any Additional Driver License Held (Current or Former Drivers Licenses)**

Driver License No: State:

Applicant Personality Evaluation

Please answer each question with 200 words or less per question.

Describe why Harris County ESD#1 should consider employing you.

What do you expect Harris County ESD#1 to provide you if you become an employee?

Why do you want to work for Harris County ESD#1