Madison County Emergency Medical District

Employment Application

Please complete the following application to be considered for employment. All applications are reviewed and valid one year from their submission date. After one year, please submit another application (if desired or applicable).

All fields marked with an asterisk are required to be completed before submitting. If you would like to further explain an answer, and have not been given space to do so, please submit it in the "Other Additions" section below.

Please email a copy of your driver's license, social security card, State of Ohio EMT Certification, cover letter and résumé to jobs@madisoncountyemd.org. Any applications submitted without these materials will not be considered.

Name (Last, First Middle)
Telephone Number
Email Address
Street Address
Apartment/Lot Number
City
State
Country
County
Date Avaliable (MM/DD/YYYY)
Are you legally allowed to work within the United States?
If you selected no, please explain
Have you ever plead guilty, no contest or been convicted of a crime?
If yes, please explain (include dates and details)
Is there any pending litigation against you?
If yes, please explain (include dates and details)
What is the State in which you hold a valid drivers license?
Driver's license number
Have you ever been fired or resigned in lieu of termination?
If yes, please explain (include dates and details)
State of Ohio Fire/EMS Certification Number
National Registry of EMTs Certification Number
Have you ever been employed by the Madison County Emergency Medical District?
If yes, from which dates (MM/YY to MM/YY)
Do you have a high school diploma?
If no, do you have a GED?
What school did you receive your diploma/GED from? (ie London High School, London, Ohio)
Have you ever served on active or reserve duty in the armed forces (provide a copy of all DD-214s in your email)?
Reference #1 Name
Reference #1 Phone Number
Reference #1 Address
Reference #2 Name
Reference #2 Phone Number
Reference #2 Address
Reference #3 Name
Reference #3 Phone Number
Reference #3 Address
Other Additions
Do you certify that you agree and understand the disclosure listed below this application?

	Submit Application

Thank you for your interest in applying with the Madison County Emergency Medical District!

All applications will be reviewed periodically through the year, and will be considered when a new testing process is announced. We will contact you with a test date if your application is accepted. There is no need to contact the District in any way, we will ensure you are contacted if you are not ruled out by any of the answers you have given in this application.

Be sure to submit a copy of your driver's license, social security card, State of Ohio EMT Certification, cover letter and résumé to jobs@madisoncountyemd.org. Any applications submitted without these materials will not be considered.

If you would like to learn more about the hiring process, or find out when the current part-time list expires, you can do so by visitng http://www.madisoncountyemd.org/employment-opportunities.

Thank you again for your interest, and good luck!

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Hiring Disclosure

By submitting this online application, you certify that, to the best of your knowledge and belief, all statements made herein or attached are complete and accurate. You understand that any false statements later disclosed will cause loss of your right to examination, certification, appointment or retention of position and may subject your to prosecution under Ohio Revised Code Section 291.13.

Furthermore, you herby authorize the Madison County Emergency Medical District to contact prior employers, educational institutions and references listed below to obtain any and all information related to your past work performance, experience or education.

Madison County Emergency Medical District is an equal opportunity employer.

Madison County Emergency Medical District

Proudly Serving Our Community Since 1981

Employment Application

Hiring Disclosure