Tri-County Application

This form is for initial screening. Additional documents (e.g., certification copies, resume) may be requested during interviews.

Section 1: Personal Information

Position Applying For:

Section 2: Education and Qualifications

Highest Level of Education Completed:

Section 3: Work Experience

Section 4: Certifications and Licenses

Current EMT/Paramedic Certification Level:
Registered with National Registry of Emergency Medical Technicians (NREMT)?
If not Indiana, is reciprocity completed with the State of Indiana?
CPR/BLS Certification:

Section 5: Background and Health (Required for All; EMT/Paramedic May Require Additional Checks)

Have you ever been convicted of a felony within the past 5 years?
Consent to Background Check:
Physical Ability: Can you lift 50+ lbs (for field roles)?

Section 6: References

Provide 2 Professional References:

Section 7: Acknowledgment/Authorization

“l certify that the facts contained in the application are true and completed to the best of my knowledge and understand that, if employed, falsified statements on the application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for. any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative"