Employment Application

4. Work history

List up to five employers, most recent first. At least one entry is required (use employer name "N/A" if no prior employment).

Employer #1 *

Employer *

Job title

City / State

Start (month/year)

End (month/year or Present)

Duties / responsibilities

Reason for leaving

Employer #2

Employer

Job title

City / State

Start (month/year)

End (month/year or Present)

Duties / responsibilities

Reason for leaving

Employer #3

Employer

Job title

City / State

Start (month/year)

End (month/year or Present)

Duties / responsibilities

Reason for leaving

Employer #4

Employer

Job title

City / State

Start (month/year)

End (month/year or Present)

Duties / responsibilities

Reason for leaving

Employer #5

Employer

Job title

City / State

Start (month/year)

End (month/year or Present)

Duties / responsibilities

Reason for leaving

5. Education

Optional but recommended. Add schools, degrees, or training programs.

School / program #1

School / institution

Degree / credential

Field of study

Year completed / expected

Notes

School / program #2

School / institution

Degree / credential

Field of study

Year completed / expected

Notes

School / program #3

School / institution

Degree / credential

Field of study

Year completed / expected

Notes

School / program #4

School / institution

Degree / credential

Field of study

Year completed / expected

Notes

6. Certifications & credentials

Select all that apply

AHA ARC HSI Faculty Other

Other certification details

Credential / instructor numbers and expiration dates

Years of teaching / related experience

7. References

Provide at least two references (professional preferred).

Reference #1 *

Name *

Relationship

Phone

Notes

Reference #2 *

Name *

Relationship

Phone

Notes

Reference #3

Name

Relationship

Phone

Notes

8. Resume, essay & emergency contact

Resume *

PDF, DOC, or DOCX. Max 5 MB.

How did you hear about Code Blue?

Cover letter / Why Code Blue

Additional information

Emergency contact

Name

Phone

Relationship

9. Agreements & electronic signatures

Code Blue CPR Services collects employment application information and electronic signatures for onboarding documents. Form I-9 Section 2 / remote document inspection and any legally required in-person or authorized remote verification remain the employer responsibility and are not completed solely by this form.

I consent to use electronic signatures for the documents below and understand that my typed name, drawn signature, date/time, and IP address will be recorded for audit purposes. *

Background Screening Disclosure *

Other / custom agreement

Please review this disclosure and e-sign below.

Open / download PDF

I have reviewed this document (required)

Typed full legal name *

Draw signature *

Employment Application Packet

Other / custom agreement

Reference copy of the employment application packet. Complete the online wizard below to apply.

Open / download PDF

I have reviewed this document

Typed full legal name

Draw signature

Form I-9 (Employment Eligibility Verification) *

Form I-9 (Employment Eligibility)

Review USCIS Form I-9. Completing Section 1 and presenting acceptable documents is required by law no later than your first day of employment after a job offer. Signing below acknowledges you received and reviewed this form. Employer Section 2 verification is completed separately by Code Blue CPR Services.

Open / download PDF

I have reviewed this document (required)

Typed full legal name *

Draw signature *

Form W-4 (Employee Withholding Certificate) — 2026 *

Form W-4 (Employee Withholding)

Review the IRS Form W-4, complete your personal withholding information as directed by your employer after hire if needed, and sign below to acknowledge you received and reviewed this form.

Open / download PDF

I have reviewed this document (required)

Typed full legal name *

Draw signature *

I certify that the information in this application is true and complete to the best of my knowledge. I understand that false statements may result in rejection or termination. *