GCEAS Application

This application will be discarded after 90 days if all necessary documents have not been turned in. This information is completely up to the applicant to be turned in. All fields with a * must be completed.

*Social Security Number will be obtained on the day of the interview

Address

PERSONAL HISTORY

PHYSICAL LIMITATIONS

MILITARY EXPERIENCE

Only complete the next question if you have served in the US Armed Forces.

EDUCATION

Please list the name, location, if you graduated, and your degree/diploma for each of the following questions.

DRIVING HISTORY

REFERENCES

List three character references with names, addresses, and phone numbers. DO NOT use family members.

I hereby authorize the Greenbrier County Emergency Ambulance Service and/or its authorized agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application for Employment and/or obtaining other information which is material to my qualifications for employment.

I release the Greenbrier County Emergency Ambulance Service and/or its authorized agents which obtain information, and any person or entity which provides information, pursuant to this authorization from any and all liabilities, claims or lawsuits in regard to the information obtained from any and all of the above referenced sources used.

If employed, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I understand that, if I am dismissed for any of the above reasons, I will be paid only through the day of me release, if classified as a paid employee.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

EMPLOYMENT HISTORY

Please give accurate, complete, full-time and part-time employment information. Start with the most present or most recent employer.

CERTIFICATIONS

Copies of current certifications must be turned in at the time of your interview.

DISCLOSURE

As part of our hiring background and investigation, we may obtain consumer reports or prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, , criminal history reports and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are also entitled to a copy of your Rights Under the Fair Credit Reporting Act.

AUTHORIZATION TO RELEASE INFORMATION

*Social Security Number will be obtained on the day of the interview

I do hereby authorize verification of all information in my employment application from all sources of employment, education, motor vehicle, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agent of HRS, to obtain, whether the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively by HRS for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. I agree to provide additional information that may be requested to process my employment application. I authorize without reservation, any party or agency contacted by HRS to furnish the abovementioned information. This authorization is valid during the course of my employment to the extent permitted by law.

(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)

I have the right to make a request HRS-Verified Person, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which HRS, has previously furnished within the two year period preceding my request.

I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

*Please bring copies of your driver's license and all certifications to your interview.

The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws such as HIPAA. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please delete it from all electronic and digital memory, electronic media and storage devices. Contact the sender by reply email.