Job Application Form

Employment History Information
Work History: Current and previous 2 employers (most current employer listed first)
Most Recent Employer Name

First NameLast Name
City, State
Position Held
Start Date

MonthDayYear
Date Finished

MonthDayYear
Employer phone

Area CodePhone Number
Supervisor name

First NameLast Name
Describe your duties:
Reason for leaving
May we ask this employer for a reference?*

YesNo
NEXT EMPLOYER
Employer Name

First NameLast Name
City, State
Position Held
Start Date

MonthDayYear
Date Finished

MonthDayYear
Employer phone

Area CodePhone Number
Supervisor name

First NameLast Name
Describe your duties:
Reason for leaving
May we ask this employer for a reference?*

YesNo
NEXT EMPLOYER
Employer Name

First NameLast Name
City, State
Position Held
Start date

MonthDayYear
Date Finished

MonthDayYear
Employer phone

Area CodePhone Number
Supervisor name

First NameLast Name
Describe your duties:
Reason for leaving
May we ask this employer for a reference?*

YesNo

EMS BACKGROUND
State DMV License*
Have you ever driven an emergency vehicle? If so,what type and how long?*
Has you license ever been suspended/revoked? When and what for?*
List most recent traffic offense citation including date, place, and disposition.*
List any other taffic offense citation including date, place, and disposition.*
List any accidents you were cited for in the last 5 years.*
Last convicted criminal offense including date, place, and disposition.*
Have you ever had a judgement in a medical mapractice suit?*
State "YES" or "NO" If yes, please describe in full
Has your insurer ever paid a claim on your alleged malpractice?

PLEASE READ CAREFULLY
I understand and agree that, if hired my employment is "at will" and is not for a definate period and may, regardless of circumstances, be terminated at any time without prior notice by the Company. I further acknowledge that no contract of employment will be valid against the company unless signed by the Chief Operating Officer of the Company.

I acknowledge that as a condition of my employment, I will be required to agree to be bound by the terms of and sign the Company. Failure to sign this Agreement shall result in revocation of my offer of employment.
Choose ONE:*

I ACCEPTI DO NOT accept
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APPLICATON FOR EMPLOYMENT