EMS Application

The information requested on this questionnaire is for the use of the City of Eagle Grove E.M.S., to assist in the determination of your suitability for the position of:  EMT or Driver. All questions must be answered completely. Any intentional omission or alteration of facts can be grounds for dismissal if hired, or removal from further consideration.

By your request heron, you grant all rights to the City of Eagle Grove, or the designated agents thereof, to fully investigate all information provided by you on this questionnaire. This shall include, but not limited to, contacting selected or all persons named by you on this questionnaire and inquire as to your character, work performance, personality, and other considerations deemed necessary by the City of Eagle Grove.

Also, by your signature hereon, you waive the right to review any, and all information gathered in the course of the investigation as well as release the City of Eagle Grove, its designated agents, and all persons connected with the investigation, from all liability, which may be brought about by said investigation.

I certify that I have read and fully understand the above statement and its complete content and agree to all conditions.: *

Position Applying for?

Are you willing to relocate if job requires it?

Are you 18 or Older?

Are you legally eligible to work in the U.S.?

THE CITY IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE AGAINST ANY EMPLOYEE OR APPLICANT FOR EMPLOYMENT ON THE BASIS OF AGE, RACE, RELIGION, CREED, COLOR, SEX, NATIONAL ORIGIN, OR DISABILITY. DO YOU UNDERSTAND?

Have you previously applied for employment with the City

The term "convicted" includes a guilty plea, a plea of nolo contendere or no contest, a deferred judgment of adjudication, and adjudication of guilt or delinquency as a minor. Do You Understand?

If you answer "yes" to any of the following questions, you must provide details. Do You Understand?

Have you ever been convicted of a felony?
Have you ever been convicted of a serious misdemeanor?

Convictions will not necessarily bar you from employment. We will consider the number, nature and seriousness of the convictions in making our decision. Do You Understand?

Have you ever been convicted of or forfeited a bond for driving under the influence of drugs or alcohol (CUI) or for driving while intoxicated (DWI)?



* - denotes required field