Employment Application

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

If you have any questions about the hiring process or this application, please contact:

hiring@skamaniaems.com

YOU MAY RETURN APPLICATIONS AS FOLLOWS:

In Person or Via Postal Mail	Via Electronic Mail

Skamania County EMS	hiring@skamaniaems.com

253 SW First Street

PO BOX 338	(must be submitted as a PDF)

Stevenson, WA 98648

Employment Application checklist

The following list represents documents that need to be included with your application. Please submit clear, true, copies, not the original document or record. Complete and return this checklist with your application.

Applications will not be considered if required documents are not included.

REQUIRED DOCUMENTS
Valid, State Issued Driver License
Abstract Driving Record (less than 30 days old)
Education records, which may include: High School Diploma or Transcripts Showing Graduate Status – or – GED – or – Course/College Transcripts for EMS Certification
State EMS Certification -and/or- National Registry
AHA CPR for the Professional Rescuer -and/or- Healthcare Provider BLS Card
NIMS Documentation
Background Check and Criminal History Supplement Form: WSP Background Check Authorization Form Criminal History Information Supplement Form Reference Authorization Check

OPTIONAL DOCUMENTS
Resume
Certifications that are supplemental to the required items and may be listed in your education or work history as applicable to the position

Employment Application	Date received: ________________

Applicant INFORMATION (if submiting a printed copy applicants must print neatly)
Last Name	First	M.I.	Birthday
Street Address	Apartment/Unit #
Mailing Address
City	State	ZIP
Phone	E-mail Address
Alternate Phone	Date Available To Start
Mark all positions applying for:	󠄉☐ Full Time ☐ Part Time ☐ Volunteer ☐ EMT ☐ PARAMEDIC ☐ Other (Administrative Positions) ☐ Resident EMT Program
Are you a citizen of the United States?	YES ☐	NO ☐	If no, are you authorized to work in the U.S.?	YES	NO
Have you ever worked or volunteered for SCEMS?	YES ☐	NO ☐	If so, when?
Do you have one or more moving violations in the last two years?	YES ☐	NO ☐	If yes, explain
Do you have any criminal driving citations?	YES ☐	NO ☐	If yes, explain
Have you ever been convicted of a felony?	YES ☐	NO ☐	If yes, explain
Education (attach additional PAGES as NEEDED)
High School	Address
From	To	Did you graduate?	YES ☐	NO ☐	Degree
College	Address
From Click or tap here to enter text.	To	Did you graduate?	YES ☐	NO ☐	Degree
College/ Other	Address
From	To	Did you graduate?	YES ☐	NO ☐	Degree
Previous Employment (list all employeers, attatch additional pages as needed)
Company	Phone
Address	Supervisor
Job Title	Salary (OPTIONAL)	$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?	YES ☐	NO ☐

Company	Phone
Address	Supervisor
Job Title	Salary (OPTIONAL)	$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?	YES ☐	NO ☐
Company	Phone
Address	Supervisor
Job Title	Salary (OPTIONAL)	$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?	YES ☐	NO ☐
Current State or National EMT Certifications (and attach copies of cards IF APPLICABLE)
State:	Expiration Date:
National Registry:	Expiration Date:
Other:
Please list all current EMS/Rescue related Certifications (and attach certs or training records) Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date: Type: Expiration Date:

References Please list three professional references. Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address
Disclaimer and Signature
I certify, under penalty of perjury, that my answers are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment with Skamania County Public Hospital District #1, (dba: SCEMS), as necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” relationship and may not be changed by any written document or by any conduct unless such changes are specifically acknowledged in writing by an authorized administrator for or by the Board of Commissioners of Skamania County Public Hospital District #1. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge from employment or termination of any offer of employment. I also understand that I am required to abide by all rules and regulation of the agency.
Signature	Date
Print Name:

Please attach the following to your application (applications will not be considered if requested documents are not submitted with application):

Signed Background Check Authorization

A copy of your current driver’s license.

A copy of any certification or cards you have listed in your educational experience or certification letter attesting to completed training.

A copy of your proof of high school graduation or GED or proof of higher education which would only be obtainable following graduation from high school or receipt of a GED

Any other documents you feel are pertinent to your potential employment with the agency.

A résumé may be attached but will not be accepted in place of this application.

Washington State Patrol Criminal Background Check

The Child/Adult Abuse Information background check response is limited to convictions of crimes against children or other persons, dependency proceedings, abuse of vulnerable adults, and DOL disciplinary board final decisions and any subsequent criminal charges associated with the conduct that is the subject of the disciplinary board final decision. Skamania County Public Hospital District dba Skamania County Emergency Medical Services shall use this record only in making the initial employment decisions. Further dissemination of the record is prohibited without written permission from the applicant (see Criminal History Information Supplement).

Instructions

Applicants must complete all items in this section. Type or print clearly in ink.

Submit with job application.

Pursuant to the Child/Adult Abuse Information Act, RCW 43.43.830 through 43.43.845, if the conviction record, disciplinary board final decision, or civil adjudication record shows no evidence of a crime against children or other persons, an identification declaring the showing of no evidence shall be issued to the applicant.

APPLICANT OF INQUIRY Applicant’s Name: ________________________________ Last, First, Middle Alias/Maiden Name: ______________________________ Date of Birth: ___________________ Drivers Lic Number/State:_________________________________ Secondary dissemination of this criminal history record information response is prohibited unless in compliance with RCW 10.97.050 ___________________________________________ Signature

Criminal History Information Supplement-

Self-Disclosure Form and Authorization for Repeat Background

Checks and Dissemination of Results

Criminal History Information Supplement

Child/Adult Abuse Information Act

RCW 43.43.830-43.43.842

Name:	______________________________________________________________________________________

Last, First, MI

Social Security Number:__________________________ Date of Birth:___________________________________

Have you ever been convicted of any crime against children or other persons?

☐ Yes	If yes, specify ____________________________________________________________________

☐ No

RCW 43.43.830 (5) “Crime against children or other persons” means a conviction of any of the following offenses: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second or third degree assault; first, second or third degree assault of a child; first, second or third degree rape; first, second or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second or third degree child molestation; first or second degree sexual misconduct with a minor; first or second degree rape of a child; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any other crimes as they may be renamed in the future.”

Have you ever been convicted of crimes relating to financial exploitation if the victim was a vulnerable adult?

☐ Yes	If yes, specify _________________________________________________________________________

☐ No

RCW 43.43.830 (6) “Crimes relating to financial exploitation” means a conviction for first, second, or third degree extortion; first, second, or third degree theft; first, second, or third degree robbery; forgery; or any of these crimes as they may be renamed in the future.

RCW 43.43.830 (9) “Vulnerable adult” means “vulnerable adult” as defined in chapter 74.34 RCW, except that for the purposes of requesting and receiving background checks pursuant to RCW 43.43.832, it shall also include adults of any age who lack the functional, mental, or physical ability to care for themselves.

RCW 74.34.020 (8) “Vulnerable adult” means a person sixty years of age or older who has the functional, mental, or physical inability to care for himself or herself.

RCW 43.43.830 (10) “Financial exploitation” means the illegal or improper use of a vulnerable adult of that adult’s resources for another person’s profit or advantage.

Have you ever been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor?

☐ Yes	If yes, specify __________________________________________________________________________

☐ No

Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?

☐ Yes	If yes, specify: ______________________________________________________________________

☐ No

Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult?

☐ Yes	If yes, specify: ________________________________________________________________________

☐ No

Have you ever been found by a court of law in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult?

☐ Yes	If yes, specify: _______________________________________________________________________

☐ No

I certify, under the penalty of perjury, that the statements above are true and correct.

____________________________________________	______________________

Signature	Date

Certification Concerning Criminal History outside the State of Washington

I certify, under the penalty of perjury that I have not been convicted of any of the above-listed crimes or had findings against me concerning the above listed proceedings outside the State of Washington.

____________________________________________	______________________

Signature	Date

If you cannot so certify, please specify why not: Click or tap here to enter text.

Authorization for Repeat Background Checks and Dissemination of Results

I authorize repeat background checks and dissemination of my self-disclosure information, background check results, and conviction records. I understand that Skamania County Public Hospital District will provide the records listed above only with the condition that the receiving party or parties will be notified by Skamania County Public Hospital District that they may not disclose the information to other parties, in a personally-identifiable form, without my further consent, unless the other parties are otherwise eligible under federal or state law to receive the records. I further understand that any statements that I have placed in my records commenting on contested information contained in the records listed above will be released along with the records to which they relate.

____________________________________________	______________________

Signature	Date

Dissemination of Self-Disclosure Information, Background Check Results, and Conviction Records

These records are provided to you pursuant to the above release signed by ___________________________________ (applicant) with the understanding and on condition that, you not release these records to any other person or institution or entity without the further consent of ___________________________________________(applicant).

SKAMANIA EMERGENCY MEDICAL SERVICES & RESCUE SKAMANIA COUNTY PUBLIC HOSPITAL DISTRICT 253 SW First Street ● PO BOX 338 ● Stevenson, Washington 98648 Office: 509-427-5065 Fax: 509-427-2767 Email: info@skamaniaems.com

CONSENT AND AUTHORIZATION TO CHECK REFERENCES

I ___________________________ have applied for employment with the Skamania County Public Hospital District (herein after Skamania County EMS) and have provided information about my current and/or previous employment. I authorize Skamania County EMS to conduct a reference check with my present and/or previous employer(s). I understand that this reference information may include but not be limited to verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary information and employment history.

My signature below authorizes my current or former employer(s) and references to release information regarding my employment record with their organization, and to provide any additional information that may be necessary for my application for employment to Skamania County EMS; whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Skamania County EMS from any and all liability arising from their giving or receiving information about my employment history, academic credentials or qualifications, and my suitability for employment with Skamania County EMS.

This form may be photocopied or reproduced as a facsimile or scan, and these copies will be as effective as a release or consent, as the original I sign.

Name (full, legal): _______________________________________________

Cell Phone: ____________________________________________________

Email: _________________________________________________________

Signature:____________________________	Date:_____________________