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Doddridge County Ambulance
Authority Application for Employment
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.pdf format
Download application in
Word format
Doddridge County Ambulance Authority is an Equal Opportunity
Emergency Medical Services agency and EEO/Affirmative Action
Employer committed to excellence through diversity.
Employment offers are made on the basis of qualifications
and without regard to race, sex, religion, national or
ethnic origin, disability, age, veteran status, or sexual
orientation.
PLEASE TYPE OR PRINT. Complete the entire application. You
may attach a resume, but you must still complete all
questions; or your application will be deemed incomplete and
may not be considered. Please fill out each box (don't just
indicate “See Resume.”) Applications with missing or invalid
job numbers will not be considered for any position.
Position
Applying For:
_________________________________________________________________
JOB #: ___________________
Name (Last, First, Middle):
____________________________________________________________
Other names under which
you have attended school or
been employed: _______________________
Street Address:
______________________________________________________________________
City, State & Zip:
____________________________________________________________________
Social Security Number:
_______________________________________________________________
Home Phone: ____________
Work Phone: ____________
Other Phone: ____________
Are you eligible to work in the United
States?
Yes ___ No ___
Are you 18 years of age or older?
Yes ___ No ___
If NO, what is your current age? _______
Are you currently employed at
(company)?
Yes ___ No ___
If YES, what is your current job title & department?
_______________________________________
Have you ever been employed by
(company)?
Yes ___ No ___
If YES, dates of employment & reason for leaving:
_________________________________________
Are you related to any current
(company employee)?
Yes ___ No ___
If YES, their name & their relationship to you?
_____________________________________________
If required for position, do you have a
valid driver’s license?
Yes ___ No ___
If YES, State of issuance, license #, and expiration
date: ___________________________________
How did you learn about this employment opportunity at ?
Check all that apply:
___Ad in newspaper ___Job
Bulletin (Posting) /Walk-in
___Website
___Dept. of Labor Ad in magazine
___Referral by employee
___Other:
EDUCATION
Name of School
______________________________________________________________________
City/State
__________________________________________________________________________
Did you
graduate? ______
If No, # of
years left to
graduate ________
If Yes, date
of
Graduation _______________
Degree
received ______________________________
Major _______________________
High School:
Yes ___ No ___
GED:
Yes ___ No ___
Other School:
Yes ___ No ___
College:
Yes ___ No ___
College:
Yes ___ No ___
College:
Yes ___ No ___
Other credentials/ licenses/ professional affiliations,
etc., which are relevant to the job(s) for which you are
applying.
_____________________________________________________________________
SKILLS: Please list technical skills, clerical skills, trade
skills, etc., relevant to this position. Include relevant
computer
systems and software packages of which you have a working
knowledge, and note your level of proficiency (basic,
intermediate, expert)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
WORK EXPERIENCE-Please detail your entire work history.
Begin with your current or most recent employer. If you held
multiple positions with the same organization, detail each
position separately. 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: {Doddridge County Ambulance Authority} reserves
the right to contact all current and former employers for
reference information.
Dates Employed (most recent
position)
From _________ To ___________
Full time / Part-time
If part-time, # hrs./wk: ___________
Title: ______________________
Starting Salary: ______________
Organization Name and Address:
________________________________________________________
___________________________________________________________________________________
Final Salary: ______________
Supervisor’s Name, Title and
Phone #:
____________________________________________________
Other Reference Name, Title and
Phone #: ________________________________________________
Contact my current references: ______At any time ______
Only if I am a finalist candidate
Primary duties:
_______________________________________________________________________
Reason for Leaving:
___________________________________________________________________
Dates Employed (most recent
position)
From _________ To ___________
Full time / Part-time
If part-time, # hrs./wk: ___________
Title: ______________________
Starting Salary: ______________
Organization Name and Address:
________________________________________________________
___________________________________________________________________________________
Final Salary: ______________
Supervisor’s Name, Title and
Phone #:
____________________________________________________
Other Reference Name, Title and
Phone #: ________________________________________________
Contact my current references: ______At any time ______
Only if I am a finalist candidate
Primary duties:
_______________________________________________________________________
Reason for Leaving:
___________________________________________________________________
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
Doddridge County Ambulance Authority 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 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 Doddridge County Ambulance Authority
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, to file a State
security questionnaire and State loyalty oath, and to
comply with company and departmental regulations. I
understand that if employed on a temporary basis, I would be
paid for hours worked only, and would
be ineligible for benefits including paid time off. If
employed on a regular, benefits-eligible basis, I understand
that I would be required to make mandatory
contributions to the Doddridge County Ambulance Authority
Retirement System or to an optional retirement program, if
applicable. I understand that any benefits I receive may be
subject to change or discontinuation at any time without
prior notice. I understand that the first SIX MONTHS of
regular employment represent a
provisional period, during which I would not be eligible to
apply for transfer or promotion and during which I may be
terminated without right of appeal.
Applicant Signature: _______________________________________
Date: ________________
Return to:
Randy Flinn
Executive Director
P. O. Box 227
Smithburg, WV 26436
Or email to rflinn66@gmail.com
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