Print this application and mail to 135 W 7th st. Eureka, CA 95501 or fax to 707-442-5903

City Ambulance of Eureka, Inc.

APPLICATION FOR EMPLOYMENT

Date:____________________________ 
1.  Your name: _______________________________________________________________________________________________

First     

Middle

Last  

 
Is any additional information, such as change of name, use of an assumed name or nickname, required to enable us to verify your entire employment history, references, educational background, credit history, required licensing and/or certifications, if applicable, and criminal record, if any,  if  a comprehensive background investigation is deemed necessary? If yes, please indicate what names should be referred to: 
____________________________________________________________________________________________________________
2.   Your present residence address:
____________________________________________________________________________________________________________

Street

City

State

Zip Code
 
3.   Your present mailing address:
____________________________________________________________________________________________________________

 P.O. Box or Street

 City

State Zip Code
 
4.   Telephone Number: Home: ________________________                       Work or Message: _______________________
 
4(a).   Social Security Number:  ________________________
 
5.   Name and address of parent or guardian if applicant is a minor 
 
Name: ______________________________________________________________________________________________________
 
Address:  ___________________________________________________________________________________________________
Street City State Zip Code
 

6.   Name, address and telephone number of person to be notified in case of an accident or emergency: __________________________
____________________________________________________________________________________________________________
 
Hire is subject to verification that you meet legal age requirements.
 

7.   Can you, after employment, submit verification of your legal right to work in the United States? _____    Such proof may be

       required after employment.

 
8.   City Ambulance of Eureka, Inc. is an equal opportunity employer. This means that employment decisions are based on merit and business needs and not on race, color,  national origin, ancestry, sex, sexual orientation, age, religion, creed, mental or physical disability, medical condition, marital status, citizenship status, military service status, or any other factor rendered unlawful by federal, state, or local law.
 

9.   By whom were you referred for a position here?  _____________________________________________________________
 

9(a).    If you were not referred, how did you learn of the opening? __________________________________________________
 
____________________________________________________________________________________________________________
 
10.   Please provide the names and telephone numbers of persons not related to you who will provide professional or character references on your behalf.
 
____________________________________________________________________________________________________________

Name

 Telephone Number
 
____________________________________________________________________________________________________________

Name

 Telephone Number
 
____________________________________________________________________________________________________________

Name

 Telephone Number
 

11.   Date available to begin work:  ________________________________________________________________________________
 

12.   Position(s) applied for:  _____________________________________________________________________________________
 

13.   Are you applying for a full-time or part-time position? ____________________________________________________________
 
        a.    If part time, please specify what days and hours you are available: _______________________________________________
 

14.   Have you ever applies for employment at City Ambulance of Eureka, Inc. Previously?  __________________________________
        a.  If so, when?  __________________________________________________________________________________________
 
        b.  Were you previously employed here? ______________________________________________________________________
 
         If so, when?  ____________________________________________________________________________________________
 
15.   Have you ever been convicted of any crime, excluding marijuana- related conviction more than two years old? _______  Please note that a conviction will not necessarily disqualify any applicant from the job applied for.
 

16.   Please describe any skills acquired during service in the armed services which would assist you in performing the job applied for:
 
____________________________________________________________________________________________________________
 
____________________________________________________________________________________________________________
 
____________________________________________________________________________________________________________
 
17.   Please indicate your education background:
School or Agency City Graduated Subjects

______________________________________________________________   Yes  ڤ  Noٱ  _________________________________
High School
 

______________________________________________________________   Yes  ڤ  Noٱ  _________________________________
College
 

______________________________________________________________   Yes  ڤ  Noٱ  _________________________________
Post Graduate
 

______________________________________________________________   Yes  ڤ  Noٱ  _________________________________
Business/Trade
 

______________________________________________________________   Yes  ڤ  Noٱ  _________________________________
Other
 

18.    Indicate present or most recent employer: _____________________________________________________________________
 

18(a).   Full-time or part-time (state hours per week): ________________________________________________________________
 

18(b).   Position Title: _________________________________________________________________________________________
 

18(c).   Immediate supervisor: ___________________________________________________________________________________
 
18(d).   Address:  _____________________________________________________________________________________________
Street City State Zip Code
 

18(e).   Telephone:  ___________________________________________________________________________________________
 

19.  Please list the last three employers, starting with the second most recent.
 

1.   Name of employer:  ______________________________________ Immediate Supervisor: _______________________________
 

Address:   ______________________________________________________________Telephone: ___________________________
 

Position:  __________________________________________________ Dates: From: ______________ To: ____________________
 

Reason for Leaving: ___________________________________________________________________________________________
 

2.   Name of employer:  ______________________________________ Immediate Supervisor: _______________________________
 

Address:   ______________________________________________________________Telephone: ___________________________
 

Position:  __________________________________________________ Dates: From: ______________ To: ____________________
 

Reason for Leaving: ___________________________________________________________________________________________
 

May we contact these employers?    Yes  ٱ   No  ٱ
 

Please indicate any employers you would prefer we not contact: _______________________________________________________
 
___________________________________________________________________________________________________________
 
 

PLEASE NOTE THE FOLLOWING:
 I understand that City Ambulance of Eureka, Inc. will thoroughly investigate my entire employment history, references, educational background, credit history, required licenses and/or certifications, if applicable, and criminal record, if any, and I expressly authorize City Ambulance of Eureka, Inc. to verify all information provided in this employment application, related documents and/or employment related interviews or discussions.
 
 I expressly authorize City Ambulance of Eureka, Inc. to conduct a search of my person or locker at any time and waive any or all claims which might arise from such searches.
 
A medical examination, which may include a test for drugs and alcohol, may be required after an offer of employment is made to a job applicant and before the applicant begins employment duties. I expressly agree to present myself to a physician chosen by City Ambulance of Eureka, Inc. if requested to do so by City Ambulance of Eureka, Inc. after an offer of employment is made and before my employment begins and also at any time during my employment.  All medical information thus obtained will be treated in a strictly  confidential manner. Refusal to take the entrance examination and/or submit to a blood or urine sample for testing may result in a withdrawal of City Ambulance of Eureka, Inc.‘s conditional offer of employment and a denial of employment.
 
I understand there are no oral or implied contracts of employment at City Ambulance of Eureka, Inc.  I understand that this application does not constitute an offer of employment or an employment contract. If I am hired by City Ambulance of Eureka, Inc., I understand that my employment will be at-will, and that either City Ambulance of Eureka, Inc. or I can terminate my employment at any time, with or without notice, with or without “cause,” for any reason or no reason at all.
 
I understand that if a dispute arises out of or related to the employment relationship, including termination of  employment, City Ambulance of Eureka, Inc. and I agree to resolve all such disputes pursuant to City Ambulance of Eureka, Inc.’s Arbitration Policy, distributed with the Employee Handbook.
 
I have read this application, and understand it completely.
 
Date: ________________________________

________________________________________________

Signature of Applicant