Accepting Applications for a 911 Emergency Dispatcher

Name

First Middle Last

Other Names Used

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Best Time to Call

: HH

MM

Email Address

May we contact you at work?

Yes
No
N/A

Work Telephone Number

Best Time to Call

: HH

MM

Have you ever been employed by C.C.E. Central Dispatch Authority?

Yes
No

Start Date

End Date

As a

Are you legally eligible for employment in the United States?

Yes
No

(Proof of U.S. Citizenship or immigration status will be required upon employment)

Type of Employment Desired

Full Time
Part Time
Temporary
Seasonal

Will you work overtime if required?

Yes
No

Date available for work

Do you have a valid driver’s license?

Yes
No

License Number

Class

State

Expiration Date

Have you ever had your driver’s license suspended or revoked?

Yes
No

If yes, please explain. Include dates, places, and nature of offenses.

Have you ever been convicted, or entered a guilty plea or no-contest for any felony?

Yes
No

Note: a “yes” answer will not automatically disqualify you from employment with C.C.E. Central Dispatch

If yes, please explain. Incude dates, places, and nature of offenses.

Are you presently under indictment for any felony offense?

Yes
No

If yes, please explain. Include dates, places, and nature of offenses. Do not include information for any charges that have been dismissed or are no longer pending.

Have you ever been dismissed from any job?

Yes
No

If yes, please explain.

Educational Background

Check highest grade completed:

High School:

College:

1
2
3
4

Graduate Work:

Yes
No

Secondary Education

College/University/Trade School	City/State	Certificate/Degree	Major

If you are fluent in any languages other than English, please list:

Employment History

List your complete employment history for the past ten years, starting with your most recent employer. List all positions held, including military experience, part-time summer and/or volunteer work periods of employment; do not omit any employers. Explain any gaps in employment in comment section. If you are submitting a resume, you are still required to summarize your job responsibilities in the space provided.

Current Employer

Employer Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Dates Employed

From

To

Starting Salary

Hourly
Weekly
Monthly

Final Salary

Hourly
Weekly
Monthly

Contact for employment verification:

Name

First Last

Telephone

May we contact current employer?

Yes
No

Summarize your job responsibilities

Reason for Leaving

Previous Employer

Employer Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Dates Employed

From

To

Starting Salary

Hourly
Weekly
Monthly

Final Salary

Hourly
Weekly
Monthly

Contact for employment verification:

Name

First Last

Telephone

May we contact previous employer?

Yes
No

Summarize your job responsibilities

Reason for Leaving

Previous Employer

Employer Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Dates Employed

From

To

Starting Salary

Hourly
Weekly
Monthly

Final Salary

Hourly
Weekly
Monthly

Contact for employment verification:

Name

First Last

Telephone

May we contact previous employer?

Yes
No

Summarize your job responsibilities

Reason for Leaving

Professional/Work References:

List name and telephone number of three professional/work references who are not related to you. Please include one previous supervisor

List

Name, Company, Address	Telephone

Special Skills and Qualifications

Typing

WPM

List any PC applications you have used:

Job-Related Certificates	Date Acquired	Status: Current/Void

List special accomplishments, publications, awards and the names of professional groups of which you are or have been a member:

List any relative(s) working for C.C.E. Central Dispatch Authority:

List any additional comments and/or information you would like us to consider:

Where did you hear about us? Check all that apply

CCE Website
APCO/NENA Website
Friend/Relative
Employee Referral
Newspaper
Other

Employee Name

First Last

Newspaper:

Other:

I certify that all information on this application form is complete and accurate. I understand that any omissions or misstatements of facts are cause for rejecting my application or, if I am hired, termination of employment. I also authorize C.C.E. Central Dispatch Authority to make all necessary and appropriate investigations to verify the appropriate information provided in this application and to secure additional job-related information about me. I understand that this application is not an employment contract. Any applicant requiring accommodation for a disability should advise the Human Resources Department.

Signature

Phone

This field is for validation purposes and should be left unchanged.