Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
Are you at least 18 years of age?
*
Position for which you are applying:
What are your pay requirements?
*
Are you available to work:
If Part Time, how many hours are you available per week?
Please list what days / hours you are available to work.
Please list what days / hours you are NOT available to work.
If hired, can you furnish proof of eligibility to work in the US?
Have you ever worked for our organization?
Can you perform the essential job functions of the position with or without a reasonable accommodation as stated on the job posting?
Do you have a valid drivers license?
Drivers License #
*
Have you ever had your drivers license suspended or revoked? *
*
If Yes, Provide Details
Are you willing to submit to a pre-employment polygraph examination, drug test, and physical agility test prior to offer, and for job related reasons thereafter?
If offered the position, when are you available to start?
Name of High School
Major
# of years completed
Did you graduate?
Name of College
Major
# of years completed
Did you graduate?
Vocational / Trade School
Major
# of years completed
Did you graduate?
Other Training
Valid Drivers License:
Copy of MVR (Motor Vehicle Record)
CIIS and/or COVID-19 Vaccination Proof
Colorado Immunization Public Portal Record and/or proof of COVID-19 Vaccination
Proof of Hepatitis Immunization (Series of three)
Proof of Tuberculosis Titer Test
Copy of Colorado EMS Certification
CPR Card (Required for all)
NREMT or NREMTP Certification
IV Certification
ACLS Card (Paramedics only)
List any other relevant certifications
Most Recent Employer: Name and Address
*
Phone
*
(###)
###
####
From
*
MM
DD
YYYY
To
MM
DD
YYYY
Supervisor
*
First Name
Last Name
Reason for leaving
*
Job Title and description
*
Employer 2: Name and Address
*
Phone
*
(###)
###
####
From
*
MM
DD
YYYY
To
*
MM
DD
YYYY
Supervisor
*
First Name
Last Name
Reason for leaving
*
Job Title and description
*
Employer 3: Name and Address
Phone
(###)
###
####
From
MM
DD
YYYY
To
MM
DD
YYYY
Supervisor
First Name
Last Name
Reason for Leaving
Job Title and description
Professional Reference 1
*
First Name
Last Name
Phone
*
(###)
###
####
Company
*
Relationship
*
Professional Reference 2
First Name
Last Name
Phone
(###)
###
####
Company
Relationship
Other relevant experience
How did you hear about us?
Who referred you to us?
SUBMISSION REQUIREMENTS: - CURRENT copies of certifications and documents you checked yes to must be provided prior to interview. Once interview is scheduled, you will receive an email to upload required certifications and documents.
*
AUTHORIZATION: I certify that the foregoing answers and statements are complete and true to the best of my knowledge and belief. I understand that any false answers, deceit or fraud whatsoever during the interview and on this form will be the basis for rejection of this application or cause for dismissal if already employed, regardless of the length of employment. I authorize the Company and/or its agents to verify records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release said persons, schools and companies and law enforcement authorities from any liability for any damage whatsoever for disclosing such information. Print your name below to acknowledge the above.
*
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