Employment Application


Application Date:*
Full Name:*
Address:*
Phone:*
-
E-mail:*
DOB: *
 / 
 / 
Driver's License No.*
Status preference:*
Base Preference:*
Date Available:
 / 
 / 
Are you currently an EMT, Advanced EMT, or Paramedic?*
Position Applying for:*
Are you a citizen of the United States?*
If you are NOT a U.S. citizen, are you authorized to work in the U.S.?
Have you ever worked or volunteered for COVA? *
Have you ever been convicted of a felony? (If yes, please explain in the comments below)*
Comments:
High School:*
High School Address:
College:
College Address:
Other:
Other
Reference 1:
Reference 1 Relationship:
Reference 1 Company:
Reference 1 Address:
Reference 1 Phone:
-
Reference 2:
Reference 2 Relationship:
Reference 2 Company:
Reference 2 Address:
Reference 2 Phone:
-
Reference 3:
Reference 3 Relationship:
Reference 3 Company:
Reference 3 Address:
Reference 3 Phone:
-
Employer 1:
Employer Address 1 :
Employer 1 Phone:
-
Supervisor 1 Name:
Job Title 1:
Employer 1 Hire Date:
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Employer 1 End Date:
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Employer 1 Job Responsibilities:
Reason for Leaving Employer 1 (if any)?
May we contact employer 1?
Employer 2:
Employer Address 2 :
Employer 2 Phone:
-
Supervisor 2 Name:
Job Title 2:
Employer 2 Hire Date:
 / 
 / 
Employer 2 End Date:
 / 
 / 
Employer 2 Job Responsibilities:
Reason for Leaving Employer 2 (if any)?
May we contact employer 2?
Employer 3:
Employer Address 3 :
Employer 3 Phone:
-
Supervisor 3 Name:
Job Title 3:
Employer 3 Hire Date:
 / 
 / 
Employer 3 End Date:
 / 
 / 
Employer 3 Job Responsibilities:
Reason for Leaving Employer 3 (if any)?
May we contact employer 3?
Branch:
Date:
 / 
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To:
 / 
 / 
Rank at discharge:
Type of discharge:
If other than honorable, explain?

USDA Questionnaire

The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the gender, race/national origin of the individual applicants on the basis of visual observation or surname. 

Ethnicity:
Race: (Mark one or more)
Gender:
If possible, upload your EMT Card and any other credentials you may have. (5 MB limit)

I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

COVA Ambulance is an equal opportunity employer.

Please type your first and last name:*
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