QUINEBAUG VALLEY EMERGENCY COMMUNICATIONS, INC. APPLICATION FOR EMPLOYMENT QV is accepting applications for PART-TIME dispatchers primarily for WEEKENDS & HOLIDAY SHIFTS.
PERSONAL INFORMATION
Present Address City State Zip Code
Previous Address City State Zip Code
Are you over the age of 18 Yes No Home Phone Business/Cell Phone
Email Address:
BACKGROUND INFORMATION
Have you ever been convicted of any crime? No Yes (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? No Yes If yes, where and when?
Do you have any radio or dispatching experience? No Yes Explain:
Do you have any knowledge of the geography of Northeast CT? No Yes Explain:
Do you have any physical defects which preclude you from performing the duties outlined in the Job description? No Yes If yes, explain:
EDUCATION (name and location of school)
High School: Graduate (y/n) No Yes
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 yes no
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: