You must have JavaScript enabled to use this form. First Name Last Name Phone Number Email Address Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Available Start Date Position(s) Applying For Position(s) Applying For PRN Emergency Vehicle Operator PRN EMR PRN EMT PRN AEMT PRN Paramedic Full-Time Paramedic How did you learn about this position? How did you learn about this position? Indeed Referral County Website Job Center of Wisconsin (JCW) Handshake Newspaper Ad Facebook LinkedIn Other Who referred you? Please provide the First and Last Name of the person who referred you. Which newspaper was the ad in? Please explain how you heard about this position: Are you a Citizen of the U.S? Are you a Citizen of the U.S? Yes No Are you currently employed? Are you currently employed? Yes No Are you legally authorized to work in the U.S? Are you legally authorized to work in the U.S? Yes No Have you ever worked for Lafayette County? Have you ever worked for Lafayette County? Yes No What Department? Dates of Employment? EMS Specific Questions EMS Licensing Level EMS Licensing Level Driver EMR EMT-B AEMT Paramedic If you are not a licensed EMT, are you planning on taking the next available EMT Course? If you are not a licensed EMT, are you planning on taking the next available EMT Course? Yes No Please provide a copy of your current CPR Certification One file only.2 MB limit.Allowed types: gif, jpg, jpeg, png, pdf. Please provide a copy of your current EMS license (EMT, EMR, etc) One file only.2 MB limit.Allowed types: gif, jpg, jpeg, png, pdf. Please provide a copy of your current ACLS Certification (Paramedic) One file only.2 MB limit.Allowed types: pdf. Please Provide a copy of your current PALS Certification (Paramedic) One file only.2 MB limit.Allowed types: pdf. Highest Level of Education Completed - Select -Some High SchoolHigh School DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate High School Attended College/University Attended Areas of Study (if applicable) Other Professional Licenses or Certifications Title of Certificate, Issued by, Date Expires Military Service Record Have you ever served in the U.S. Armed Forces? Have you ever served in the U.S. Armed Forces? Yes No Branch of Service Rank at Time of Discharge Attach a Copy of Your DD214 if Discharged in Last 3 Years One file only.2 MB limit.Allowed types: pdf, png. Do you speak fluent English? Do you speak fluent English? Yes No Do you speak a second language? Do you speak a second language? Yes No What other language(s) do you speak? Resume Please upload a complete resume including your most recent employers including job descriptions, dates of employment, salary, title, and reason for leaving.One file only.16 MB limit.Allowed types: pdf, doc, docx. References Please upload at a minimum, three professional references, including how you know them, their name, title and company, email address and phone number.One file only.16 MB limit.Allowed types: pdf, doc, docx. Required Job Testing I Understand and Agree to the Following Questions Yes No That I May be Required to Undergo a Physical Examination, as a Condition of Hiring and/or Continued Employment. Yes No That I May be Required to Undergo a Drug Test, as a Condition of Hiring and/or Continued Employment. Yes No That Lafayette County May Conduct a Department of Justice Criminal History Record Check, as a Condition of Hiring and/or Continued Employment. Yes No That by selecting "Yes" I consent that typing my name below equates to a physical signature on this form. Yes No Employee/Volunteer Waiver Agreement for Employment I certify that the answers given by me in this Application and/or Background Information Disclosure (BID) are true and correct without omissions of any kind. I understand that any misleading or incorrect statements may render this Application and/or BID void and may preclude an offer of employment or may result in a withdrawal of an employment offer. If I am employed and it is subsequently discovered that any answer given by me is incomplete, misleading, or incorrect, I may be terminated because of false, incomplete, or misleading statements, answers, or omissions made by me in this application and/or BID. I agree that Lafayette County shall not be held liable in any request; if an offer of employment is precluded or my employment is terminated because of false, incomplete, or misleading statements, answers, or omissions made by me in this application and/or BID. I understand that I may be required to provide a completed DHFS Background Information Disclosure (BID) for HFS-64; and that Lafayette County may conduct a DOJ Criminal History Record Request, to verify the information given on that form. I further understand that Lafayette County may conduct a Circuit Court (CCAP) record check; an HHS Office of Inspector General (OIG), excluded individual record check; WI Sex Offender Registry Inquiry; applicable Professional Licensure or Certification verification(s); and an Out-of-State Criminal Background Check for anyone who is residing or has resided outside of Wisconsin in the last 3 years preceding the date of the inquiry. Military Discharge papers (DD-214) may also required to be submitted for any employee, who has been discharged from the military within the three (3) years preceding the records search process. By signing this agreement, I authorize pertinent companies, schools, agencies, municipalities, or persons to give to Lafayette County any information requested regarding my employment history, character, experience, and qualifications and/or suitability for employment with Lafayette County; including, a check of my fingerprints, if requested, and police record(s) for the purpose of considering my suitability for hire. I hereby forever release, discharge, and covenant not to sue any person or organization for any result of providing, obtaining, or acting upon such information. I understand that such information is sought with confidentiality and will not be released to me in any form whatsoever. The only exception to the above stated non-release of records is the Crime Information Bureau records (CIB) records. Lafayette County issues this notification that you as a current employee, prospective employee or volunteer have the right to obtain a copy of your criminal history records, if any; and acknowledges your right to challenge the accuracy and completeness of any information contained in the criminal history record; and to obtain a determination as to the validity of such challenge before final determination regarding employment/association is made by Lafayette County. Any investigations conducted, reporting, and/or employment requirements imposed under Federal or State law do not in any way impede or affect Lafayette County’s rights under applicable State employment law and/or Lafayette County Policy to deny employment. A copy of this authorization is as valid as the original and should be recognized as such. In signing this agreement; I acknowledge that I understand that I may be asked to undergo a physical examination, which may include a substance abuse screening, prior to an appointment to a position with Lafayette County; and that I may be asked to undergo said examinations and screening periodically during employment as directed by the Lafayette County Substance Abuse Policy. Any refusal to participate in said substance abuse screening either prior to an appointment to a position with Lafayette County or during employment will result in the rejection of my application and/or termination of employment. Signed (Full Name) This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Leave this field blank Print
