Application – Sumner County EMS

Fields noted with an asterisk (*) are REQUIRED fields

Position Applying for *

Part time or Full time? *

Last Name *

last name

First Name *

first name

Middle Initial *

middle initial

Email *

Street address *

street

City *

city

State *

state

Zip Code *

zip

Home phone *

home phone

Cell phone *

cell

SSN (optional)

ssn

Date first available if employment offer is made? *

Salary range desired *

Are you at least 18 years old? *

Yes

Are you a U.S. citizen? *

Yes

If not a U.S. citizen, are you eligible for lawful employment in the U.S.? (proof of identity, citizenship or legal right to work in the U.S. will be required upon hiring)

Yes

Have you ever been arrested or convicted of any law violation other than traffic violations? *

Yes

If yes, please explain (date, place, charge, disposition)

High school (Name, City, State, Graduation Year) *

College (Name, City, State, Graduation Year)

Trade School (Name, City, State, completion year)

Are you licensed to practice in any profession? *

Yes

If yes, list profession, license number and expiration date

Has your professional license ever been revoked or suspended? *

Yes

Not applicable

If yes, please explain

Military Service - Branch, Dates (To/From), Kind of Discharge

Explain any special military schooling received that would assist you to fulfill this position

Current or most recent employer name

Current or most recent employer position

Current or most recent employer dates of employment

Current or most recent employer salary

Reason for leaving (if applicable)

Please list the names of other previous employers along with dates of employment

Knowledge, skills and abilities relevant to the position in which you are applying

Additional information that could help you qualify for this position

Reference #1 (Name, City, State, Phone #) *

Reference #2 (Name, City, State, Phone #) *

Reference #3 (Name, City, State, Phone #) *

Reference #4 (Name, City, State, Phone #)

You can also email your resume to Assistant Chief Jay Austin @ jayaustin@sumnerems.org

I understand that any false answer or statement made by me on this application or any supplement that I have attached, or in connection with my application for employment with any department of Sumner County Government will be sufficient grounds for rejection of my application or immediate dismissal if I am employed. I certify that all information listed on my application is complete and accurate to the best of my knowledge. I further understand that I will not be given any opportunity to update my previous experience declarations after I have been employed. I hereby authorize Sumner County Government and its agents to conduct a thorough investigation of my background, including past employment, and agree to cooperate. I hereby release from liability all persons, companies, institutions or corporations supplying information requested pursuant to this application. I certify that the disclosures I have made are true and correct. I also understand that failure to immediately update any information provided on this application shall subject me to discipline, up to and including nonhire, for providing false information on an employment application. *

By checking this box, you are certifying that you agree with the statement above

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