Application For Employment
CITY AMBULANCE OF EUREKA, INC.
DBA CAE Transport, City Cab, Humboldt Dial-A-RIde

Middle Name

Last 4 digits of Social Security Number

Street Address

State

Zip Code

Phone

Email Address

Position Desired

Work Desired Full Time Part Time Either

Any offer of employment is conditioned upon completing Form I-9 and providing the appropriate documents for identity and work authorization. If hired, can you provide evidence of legal eligibility to work in the U.S.?

Date You Can Begin Work

Answer Each for Insurance Eligibility Purposes:

Are you 18 years of age or older? Yes No

Are you 21 years of age or older? Yes No

Are you 25 years of age or older? Yes No

If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by California or federal law.

Have you ever been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon, or act of dishonesty for which the record has not been sealed or expunged, or do you have such a case pending?

(Convictions are evaluated on a case-by-case basis for each position and are not necessarily a bar to employment). If yes, please explain:

Have you had any moving vehicle violations, accidents or DUIs in the past three years?

If yes, please indicate what type of violation(s), and how many:

Do You Use Chewing Tobacco? Yes No

Do You Smoke? Yes No

Name of High School Attended

What City And State?

Did You Graduate? Diploma GED No

Name of College or Technical School

What City and State?

Did You Graduate? Yes No

What Degree or Major?

Are You Presently Enrolled In School? Yes No

If yes, give name & location of school and expected degree date:

List current certifications/licensures (including driver license) with expiration dates related to your desired position:

List any job-related skills or accomplishments, including military service:

Your Availability For Work

Total Hours Per Week You Are Available To Work

Do You Have Any Special Requests Or Needs In A Work Schedule?:

May We Contact Your Current Employer? Yes No

Provide Three References Who Are Not Relatives
Including One Former Employer / Coworker

Reference #1

Name:

How Do You Know Them And For How Long?:

Phone Number:

Reference #2

Name:

How Do You Know Them And For How Long?:

Phone Number:

Reference #3

Name:

How Do You Know Them And For How Long?:

Phone Number:

Your Employment History:

Present or Most Recent Employer:

Name of Employer:

Job Title:

Duties:

Address:

Employment Start Date:

Employment End Date:

City:

State

Zip:

Starting Hourly Salary:

Ending Hourly Salary:

Supervisor Name:

Phone Number:

Previous Employer:

Name of Employer:

Job Title:

Duties:

Address:

Employment Start Date:

Employment End Date:

City:

State

Zip:

Starting Hourly Salary:

Ending Hourly Salary:

Supervisor Name:

Phone Number:

Another Previous Employer:

Name of Employer:

Job Title:

Duties:

Address:

Employment Start Date:

Employment End Date:

City:

State

Zip:

Starting Hourly Salary:

Ending Hourly Salary:

Supervisor Name:

Phone Number:

Paramedics and Communications Personnel:

Please provide a resume as well. Email a PDF copy of your resume to personnel@cityambulance.com. Use your full name and position desired in the subject line, and we will match it up to your application.

How Did You Find Out About Us?
And why do you have an interest in employment with our company specifically?

Have you ever been employed by us before? If so, when, and in what capacity?

To be progressive as an organization, we need employees who will enhance our team. City Ambulance of Eureka, Inc. dba City Ambulance, City Cab, and Humboldt Dial-A-Ride is looking for proactive employees who care to improve our work environment. We expect all employees to be punctual, maintain good attendance, and have a good work ethic and a positive attitude. Beyond those basic functions of your job, what can you bring to our organization that will improve the work environment for everyone? Do not use the usual resume language, such as Team Player, Reliable, Punctual, Good Work Ethic, Fast Learner, Task Oriented, etc. Tell us what is different about you, and something unique you would be willing to share with the organization.

Please Indicate Your Level of Computer Literacy Below:

EMPLOYMENT APPLICANT ACKNOWLEDGEMENT AND RELEASE
CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I understand and acknowledge that unless otherwise defined by applicable law or written agreement with City Ambulance of Eureka, Inc any employment relationship with the City Ambulance of Eureka, Inc will be “employment at will.” This means that I may resign at any time and you, the Employer, may discharge me at any time, with or without cause, and with or without advance notice.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements.

Initials: Date: