QUINEBAUG VALLEY EMERGENCY COMMUNICATIONS, INC.
APPLICATION FOR EMPLOYMENT

AS OF 9/24/08, QV is accepting applications for FULL-TIME dispatchers.  We are also accepting applications for PART-TIME dispatchers primarily for WEEKENDS & HOLIDAY SHIFTS.  Hiring preference will be given to those with:  State Certified Telecommunicators and Powerphone Emergency Medical Dispatch Certification

 

 
PERSONAL INFORMATION

Last Name   First  Name   M.I.

Social Security #

Present Address   City   State   Zip Code

Previous Address   City   State   Zip Code

Are you over the age of 18   Home Phone   Business Phone

Email Address:

BACKGROUND INFORMATION

Have you ever been convicted of any crime?
(If yes, where, when and disposition of case)

Are you now, or have you ever been a member, of a fire department or ambulance corps?
If yes, where and when?

Do you have any radio or dispatching experience?
Explain:

Do you have any knowledge of the geography of Northeast CT?
Explain:

Do you have any physical defects which preclude you from performing the duties outlined in the Job description?
If yes, explain:

EDUCATION
(name and location of school)

High School:
Graduate (y/n)

College:
Years Completed:
Degree/Certificate Obtained:

Trade/Business/Other:

EMERGENCY CONTACT

In case of emergency, the following person should be notified:
Name:   Address:   Phone:

EMPLOYMENT REFERENCES
(Begin with your most current employer)

1. Name
Address
Dates Worked -  From To
Supervisor
Duties
Reason for leaving

May we contact your current employer 

2. Name
Address
Dates Worked -  From To
Supervisor
Duties
Reason for leaving

3. Name
Address
Dates Worked -  From To
Supervisor
Duties
Reason for leaving

4. Name
Address
Dates Worked -  From To
Supervisor
Duties
Reason for leaving

ADDITIONAL INFORMATION

Please summarize any additional information necessary to describe your full qualifications and to list any additional certifications you may hold that pertain to the position being applied for.  Here is where you should indicate if you are interested in Full Time employment, Part Time employment or both

AFFIRMATION

I certify that the statements made by me on his application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.  I understand that if i knowingly make any misstatement of facts, I am subject to disqualification.

FULL NAME:
DATE: