Careers

Name (Last, First, MI):

Date:

Email:

Social Security #:

Address:

City:

State:

Zip Code:

Home Telephone:

Cell:

Date Available to Start:

Hours Requested

Full time

Part Time

Casual (24 hr. per mo.)

How did you find out about this position?

Internet

Colleague

Newspaper

Other

Do you have any relatives or friends working here?

Yes

No

POSITION INFORMATION

Position(s) Applying For:

Ambulance

Assist Care (Wheelchair van service)

Education

If so, date(s):

Prior position:

Reason(s) for leaving:

CERTIFICATION INFORMATION

Can you provide proof, if hired, that you are eligible to work in the U.S.?

Yes

No

If the position you have applied for has driving as a requirement on the job description, do you have a valid driver's license?

Yes

No

Issued by what State?

Driver's License #:

Do you have reliable transportation to get to work?

Yes

No

A conviction will not necessarily disqualify you from employment

List all moving violations (convictions) and accidents and any suspensions or revocations of your license in the last five years.

Have you ever been convicted, or plead guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended in the last 7 years?

Yes

No

If yes, please explain:

Do you have any felony charges currently pending?

Yes

No

If yes, please explain conviction: when, where and disposition and under what name:

Have you ever been excluded, or are you currently excluded from participating in any federal health program such as Medicare or Medicaid?

Yes

No

If yes, please explain:

EMPLOYMENT HISTORY

List your last three employers or volunteer activities, starting with the most recent

Employer:

Job Title:

Start Date:

End Date:

Job Description (including duties and responsibilities):

Starting salary:

Ending salary:

Supervisor:

Employer's Telephone Number:

May we contact?

Yes

No

Reason for leaving:

II. Employer:

Job Title:

Start Date:

End Date:

Job Description (including duties and responsibilities):

Starting salary:

Ending salary:

Supervisor:

Employer's Telephone Number:

May we contact?

Yes

No

Reason for leaving:

III. Employer:

Job Title:

Start Date:

End Date:

Job Description (including duties and responsibilities):

Starting salary:

Ending salary:

Supervisor:

Employer's Telephone Number:

May we contact?

Yes

No

Reason for leaving:

MILITARY Branch of Service:

Explain any gaps in employment:

PAST EMPLOYMENT

Have you been disciplined or terminated for reckless driving?

Yes

No

Have you been placed on probation or terminated for excessive absenteeism that was related to illness or injury?

Yes

No

Have you been disciplined or fired for insubordination?

Yes

No

Have you been disciplined or fired for violation of safety rules?

Yes

No

Have you been disciplined or fired for assault or fighting?

Yes

No

Have you been disciplined or fired for harassment?

Yes

No

Have you been disciplined or fired for patient abuse?

Yes

No

Have you been disciplined or fired for alcohol or drug related activity at work?

Yes

No

If you answered yes to any question above, please explain:

Answers of Yes for any of the above questions will not necessarily disqualify you from employment

EDUCATION AND TRAINING

High School:

Address

Number of years attended:

+ -

Did you graduate?

Yes

No

If not, highest grade completed:

Have you received your GED?

Yes

No

College

Address:

Number of years attended:

+ -

Did you graduate?

Yes

No

If not, highest year completed:

Degree:

Major:

Technical School:

Address:

Number of years attended:

+ -

Did you graduate?

Yes

No

If not, your highest year completed:

Certificate:

Expires

License:

Expires:

OTHER:

EMS/FIRE/LAW ENFORCEMENT SERVICE TRAINING NOT LISTED ABOVE:

EMS/FIRE/LAW ENFORCEMENT/PROFESSIONAL AFFILIATIONS (other than listed under prior employment):

Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know when considering your application, such as computer skills, foreign languages, etc.

REFERENCES

List three persons, other than relatives, who have knowledge of your work experience and/or education.

I. Name:

Address:

Occupation:

Years Known:

+ -

Telephone Number (including area code):

II. Name:

Address:

Occupation:

Years Known:

+ -

Telephone Number (including area code):

III. Name:

Address:

Occupation:

Years Known:

+ -

Telephone Number (including area code):

ACKNOWLEDGEMENT

I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment. If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform job duties. I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by the company as a condition of my employment, and I hereby give my consent to the release of all information which the Company deems necessary to determine my ability to perform job duties now or in the future. I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from this Company. I hereby authorize the Company to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release the Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. I certify that I am not now, nor have I been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded, my employment with the Company may be terminated.

Applicant's Signature:

Date:

Printed Name: