Online Application

Online Application

First Name *

Last Name *

Social Security Number

Date of Birth *

Address

City

State/Province

Zip/Postal

Country

Email Address

Phone Number *

Secondary Phone Number

Are you at least 18 years of age?

Yes

Availability

Part Time

Full Time

How did you find out about this position?

Do you have relatives/friends working here? (if yes, explain)

Position Applying for?

Have you ever worked for this organization? (if yes, please list dates)

Reason for leaving

Other Certifications

Are you eligible to work in the US?

Yes

Do you have a valid Drivers License?

Yes

Issued by what State?

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

Have you ever been convicted, or pled guilty/no contest to a felony or misdemeanor, including a DUI/DWI or similar offense?

Yes

If yes, explain:

Do you have any past/present medical issues that would keep you from performing your duties as an EMT? (Lifting restrictions, heart problems, back problems, etc)

Yes

If yes, explain:

EMPLOYMENT HISTORY

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

#1 Employer

Employer

Job Title

Supervisor

Start Date

End Date

Phone Number

May we contact?

Yes

Job Description (Duties and responsibilities)

Address

City

State/Province

Zip/Postal

Country

Reason for leaving:

#2 Employer

Employer

Job Title

Supervisor

Start Date

End Date

Phone Number

May we contact?

Yes

Job Description (Duties and responsibilities)

Address

City

State/Province

Zip/Postal

Country

Reason for leaving:

#3 Employer

Employer

Job Title

Supervisor

Start Date

End Date

Phone Number

May we contact?

Yes

Job Description (Duties and responsibilities)

Address

City

State/Province

Zip/Postal

Country

Reason for leaving:

HAVE YOU EVER BEEN

Disciplined or terminated for reckless driving?

Yes

Disciplined or terminated for excessive absenteeism?

Yes

Disciplined or terminated for insubbordination?

Yes

Disciplined or terminated for violation of safety rules?

Yes

Disciplined or terminated for assault or fighting?

Yes

Disciplined or terminated for harassment?

Yes

Disciplined or terminated for patient abuse?

Yes

Disciplined or terminated for alcohol or drug related activity?

Yes

If you answered yes to any of the questions above, please explain:

EDUCATION

HIGH SCHOOL

Name

Address

City

State/Province

Zip/Postal

Country

Years completed

Did you graduate?

Yes

Have you received your GED?

Yes

COLLEGE

Name

Address

City

State/Province

Zip/Postal

Country

Years completed

Did you graduate?

Yes

Degree

Major

OTHER COLLEGE

Name

Address

City

State/Province

Zip/Postal

Country

Years completed

Did you graduate?

Yes

Degree

Major

TECHNICAL SCHOOL

Name

Address

City

State/Province

Zip/Postal

Country

Years completed

Did you graduate?

Yes

Certificate

License

OTHER SCHOOL/TRAINING

Name

Address

City

State/Province

Zip/Postal

Country

Years completed

Did you graduate?

Yes

Certificate

License

EMS/FIRE Service related training not listed above:

EMS/FIRE/PROFESSIONAL Affiliations not listed above:

Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know:

REFERENCES

List at least three persons, other then relatives, who have knowledge of your work experience and education.

Reference #1

Name

Address

City

State/Province

Zip/Postal

Country

Occupation

Years known

Phone Number (include area code)

Reference #2

Name

Address

City

State/Province

Zip/Postal

Country

Occupation

Years known

Phone Number (include area code)

Reference #3

Name

Address

City

State/Province

Zip/Postal

Country

Occupation

Years known

Phone Number (include area code)

Reference #4

Name

Address

City

State/Province

Zip/Postal

Country

Occupation

Years known

Phone Number (include area code)

Upload Resume

Maximum file size: 10MB

Medical Emergency Ambulance also requires you to complete the ICS 100, 200, 700, and 800 online courses from the FEMA website and present these on or before you come in for an interview. We strive to better ourselves and to provide the best possible care for the community.

ACKNOWLEDGMENT

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 the 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 ever 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 *

This is your OFFICIAL DIGITAL SIGNATURE, please use your full name.

Date *