Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone *

(###)

###

####

Evening Phone

(###)

###

####

Have you ever applied with us before? *

Yes

No

Are you legally allowed to work in the United States? *

Yes

No

Are you 19 Years of Age or Older? *

Yes

No

Have you ever been convicted of a felony or criminal misdemeanor? *

Yes

No

Have you ever worked for Jackson County EMS before? *

Yes

No

Position that you are applying for. *

Select all that apply

Dispatcher

EMT-B

Advanced EMT

Paramedic

Other

I am applying for. *

Full Time

Part Time (20 Hours/Week)

Flex (48 Hours/Quarter)

Any Accreditations? *

EMT

Paramedic

Other

None

Do you have a high school diploma or equivalent? *

Yes

No

Are you able to work: *

Days

Evenings

Nights

Weekends

Holidays

12-Hour Shifts

Rotating Shifts

Are you available to work overtime? *

Yes

No

May we contact? *

Yes

No

May we contact?

Yes

No

Have you ever been discharged, asked to resign, or resigned to avoid a discharge from any position? *

Yes

No