Employment Application

Name

First Last

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Desired Hourly Rate

Referred by*

Contact Me By

What type of hours can you work?*

Preferred Station & Position

TDSHS License number*

Have you ever worked at WindsorEMS before?*

Yes

When did you work for WindsorEMS?

MM slash DD slash YYYY

Have you ever been convicted of a crime?*

Yes

Please provide dates and details.

Have you had any traffic convictions in the last 5 years?*

Yes

Please provide dates and details

Date Available*

MM slash DD slash YYYY

Have you ever been forced to resign for misconduct or unsatisfactory performance?*

Yes

Are you a military veteran?*

Yes

Are you eligible to work in the United States?*

Yes

Date of Birth?*

MM slash DD slash YYYY

Current / Last Employer*

May we contact your previous employer?*

Yes

Are you currently employed?*

Yes

Supervisor's name*

First Last

Supervisor Contact Number*

Supervisor Email*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Reason for Leaving*

What is your education level?*

High school

2-Year College

4-Year College

Location*

Did you graduate?*

Cut and Paste Resume or (list Employment History with Names & Numbers) here:*

List Three References and add any additional comments here:*

PLEASE READ CAREFULLY*

I agree

In exchange for the consideration of my job application by Windsor EMS, I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Windsor EMS, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a 105 message signed by the business office of Windsor EMS. Both the undersigned and Windsor EMS may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Windsor EMS may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Windsor EMS permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Windsor EMS from any liability as a result of such contract. I also understand that (1) Windsor EMS has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, Windsor EMS may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, Windsor EMS will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with Windsor EMS shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with Windsor EMS is terminable at will for any reason by either party. I understand that Windsor EMS does not subscribe to Workmen’s Compensation. Windsor EMS does carry a supplemental accidental policy, which does provide compensation of salary and insurance protection. I understand that if a physician places me on light duty, Windsor EMS will not be required to provide light duty to me. I understand that Windsor EMS will not tolerate sexual or any other form of unlawful harassment. I understand that I have the affirmative obligation to report it. I also understand that unlawful harassment is grounds of disciplinary action up to and including immediate dismissal.

Windsor EMS is an equal employment opportunity employer. We adhere to a policy of making employment Decision’s without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Windsor EMS depends solely on your qualifications. Thank you for completing this application form and for your interest in Windsor EMS. Your application for employment will be maintained in our Human Resources Department for six (6) months.

Signature*

Date*

MM slash DD slash YYYY

Print Name*

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