Contact Information
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:

Social Secuity #:
Drivers License #:

Home Phone:
Business Phone:
Email Address:
Employment Desired
Full Time Part Time Paid-Per-Call
Paramedic EMT Office
Personal Information
Are you at least 18 years or older? (if under 18, hire is subject to verification that you are of minimum legal age.) Yes No
If you are applying for an ambulance position, are you at least 21 years of age? (SSC Insurance requires all ambulance personnel to be at least 21) Yes No
If hired, can you provide proof of U.S. Citizenship or proof of your legal right to live and work in the United States of America? Yes No
Are you able to perform the essential functions of the job with or without reasonable accommodations for which you are applying? Yes No
If No, describe the functions that cannot be performed:
Note: We comply with the ADA and consider reasonable accommodations measures that may be necessary for qualified applicants / employees to perform essential functions. Offer of employment will be subject to a medical examination and to skill and agility tests.
Arrest History
Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No
If Yes, state the nature of the crime(s), when, where, and the disposition of the case:
Have you ever been arrested for a controlled substance, narcotic or drug offense as specified in the California Health and Safety Code Section 11590? A yes answer will disqualify an applicant from employment. Yes No
Have you ever been arrested for a sexual offense as specified in the California Penal Code Section 290? Yes No
If Yes, please explain:
Drivers License Information
Do you have a valid California Drivers License? Yes No
Do you have a valid California Ambulance Drivers License? Yes No
Are you currently employed? Yes No
Education, Training, and Experience
High School, City, State: Years: Graduate?
Yes
Subject Studied Degree / Diploma
College, City, State: Years: Graduate?
Yes
Subject Studied Degree / Diploma
Vocational, City, State: Years: Graduate?
Yes
Subject Studied Degree / Diploma
Health Care, City, State: Years: Graduate?
Yes
Subject Studied Degree / Diploma
Do you have any other experience, training, qualifications or skills, which you feel make you especially suited for work at Sequoia Safety Council? If so, explain.
License / Certificate Information
Answer the following questions if you are applying for a professional position:
Are you licensed / certified for the job applied for? Yes No
Name of license / certification Issuing State License / Certification Number
Has your license / Certification ever been revoked? Yes No
If Yes, please explain:
Employment History
List below all past and present employment starting with your most recent employer (last 10 years). Account for all periods of unemployment.
Name of Employer:
Type of Business:
Phone Number: Supervisors Name:
Your position and Duties:
Date of Employment: to
Name of Employer:
Type of Business:
Phone Number: Supervisors Name:
Your position and Duties:
Date of Employment: to
Name of Employer:
Type of Business:
Phone Number: Supervisors Name:
Your position and Duties:
Date of Employment: to
Name of Employer:
Type of Business:
Phone Number: Supervisors Name:
Your position and Duties:
Date of Employment: to
Name of Employer:
Type of Business:
Phone Number: Supervisors Name:
Your position and Duties:
Date of Employment: to
Military Service
Have you obtained any special skills or abilities as the result of military service? Yes No
If Yes, please explain:
References
List below three (3) persons not related to you who have knowledge of your work performance within the last three years. Please do not any previous listed supervisors.
Name:
Address:
Occupation: Phone Number:
Years Acquainted: Cell Number:
Name:
Address:
Occupation: Phone Number:
Years Acquainted: Cell Number:
Name:
Address:
Occupation: Phone Number:
Years Acquainted: Cell Number: