Application for Employment
Are you legally eligible for employment in the United States?
CHECK Position applying for:
High School
GED or Diploma
Years Completed
College/Vocational School
Degree or Certification
Years Completed
Degree or Certification
Years Completed
Other Training
Degree or Certification
Years Completed
Degree or Certification
Years Completed
Professional Memberships and Licences
(You need not disclose membership in professional organizations that may reveal information regarding race, color, sex, religion, national origin, ancestry, age,
disability, marital status, veteran status or any other protected status.)
Have you ever been convicted of, pled guilty to, or entered into
a pre-trial agreement or similar program with respect to a felony
or misdemeanor other than a minor traffic offense?
(A conviction will not necessarily automatically disqualify you for employment.  Rather such factors as age and date of conviction, seriousness and
nature of the crime, rehabilitation will be considered.)
Have you ever been accused of sexual harassment?
Employment History
List last employer first, including U.S. Military Service

I understand that the Fountain County Ambulance Service will run a criminal background check on me.  I also understand that I must be in good physical condition to
be a member of this department.  Not having any condition that would impair me or my action in the event of an emergency with this department.  I hereby
authorize Fountain County Ambulance Service to obtain any records pertaining to myself for the benefit of establishing and meeting the requirements of this
department.  I understand that the information in this application will not be available to other agencies or private individuals.
Place E-Signature:

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Fountain County to
verify their accuracy and to obtain reference information on my work performance.  I hereby release Fountain County from any/all liability of whatever kind and
nature which, at any time, could result from obtaining and have an employment decision, based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the
employer.  However, I further understand that neither the policies, rules, regulations of employment nor anything said during the interview process shall be deemed
to constitute the terms of an implied employment contract.  I understand that any employment offered is for an indefinite duration and at will and that either I or the
employer may terminate my employment at any time with or without notice or cause.
Place E-Signature
With every application, the following items need to be included:

Current state Certification or license
Current CPR card
Valid Driver’s License
Any other Certifications pertaining to EMS