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2. BCEAA Employment Application

4. Position applied for:*
5. Date of Application:*
   Date of Application:
7. Full Name (First, Middle, Last):*
9. Address:*
11. Phone Number:*
12. Email:
14. If you are under 18 years of age, can you provide required proof of your eligibility to work?

    1. Yes
    2. No
15. Have you ever filed an application with us before? *

    1. Yes
    2. No
17. Have you ever been employed by BCEAA before? *

    1. Yes
    2. No
18. Are you currently employed? *

    1. Yes
    2. No
20. May we contact your present employer? *

    1. Yes
    2. No
21. Are you prevented from lawfully becoming employed in this country because of Visa and Immigration status? *

    1. Yes
    2. No
23. On what date would you be available to start work? *
    On what date would you be available to start work?
24. Are you able to work:*

    1. Full Time
    2. Part Time
    3. Per-Diem
26. Are you currently on a lay-off status that is subject to recall?*

    1. Yes
    2. No
27. Has your drivers license ever been suspended or revoked? *

    1. Yes
    2. No
29. Have you ever been convicted of a felony? *

    1. Yes
    2. No
30. If "YES"explain:
32. Drivers License number, issuing state, expiration date:*
33. Do you have any special endorsements on your license? *

    1. Yes
    2. No
35. List Special Endorsements if "Yes":

37. EMS Certification

39. NREMT Cert #, Level, Expiration Date:
41. State of Certification, Cert #, Expiration Date:
43. How long have you been certified at your current level?
45. Please list all your other relevant EMS and public safety certifications or training:

47. Employment History 1

49. Business Name:
50. Type of Business:
52. Business Mailing Address:
54. Last Position held:
55. Supervisor Name and Contact #:
57. Describe the work you performed:
59. Reason for leaving:
61. Dates employed (From - To):
    Dates employed (From - To): Start Date

    —

    Dates employed (From - To): End Date
62. Starting/Ending Salary:
64. Full Time or Part Time:

    1. Full Time
    2. Part Time

66. Employment History 2

68. Business Name:
69. Type of Business:
71. Business Mailing Address:
73. Last Position held:
74. Supervisor Name and Contact #:
76. Describe the work you performed:
78. Reason for leaving:
80. Dates employed (From - To):
    Dates employed (From - To): Start Date

    —

    Dates employed (From - To): End Date
81. Starting/Ending Salary:
83. Full Time or Part Time:

    1. Full Time
    2. Part Time

85. Education

87. High School (Name of school / years completed / diploma or degree):
89. Undergraduate (Name of school / years completed / diploma or degree):
91. Graduate (Name of school / years completed / diploma or degree):

93. Miscellaneous

95. Describe any specialized training, apprenticeship skills, and extra-curricular activities:
97. Indicate any foreign languages you can speak, read, and/or write:

99. References

101. Name:*
102. Phone #:*
104. Address:*
106. Employer:
107. Title:
108. Relationship:*
112. Name:*
113. Phone #:*
115. Address:*
117. Employer:
118. Title:
119. Relationship:*
123. Name:*
124. Phone #:*
126. Address:*
128. Employer:
129. Title:
130. Relationship:*

132. Affirmative Action

     Answering any of the questions listed below is voluntary on the part of the applicant. The information collected will help Berkeley County to ensure that there is no discrimination in hiring practices by the county. These questions have been added to the application in compliance with Berkeley County’s Affirmative Action Policy. 

134. Gender:

     1. Male
     2. Female
135. Ethnic background:

     1. American Indian or Native Alaskan
     2. Asian or Pacific Islander
     3. Black (Not of Hispanic Origin)
     4. Hispanic
     5. White (Not of Hispanic Origin)

137. Document Uploads

139. Upload Documents:
Leave This Blank:


141. 1. Receive an email copy of this form.
142. Email address

     This field is not part of the form submission.

143. Submit Submit and Print

* indicates a required field