Personal Details (* indicates required fields) |
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| * Social Security Number: |
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| * Date of Birth: |
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| * First Name: |
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| * Last Name: |
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| * Middle Name: |
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| * Email: |
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| * Address: |
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| * City: |
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| * State: |
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* Zip:
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| * Phone: |
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Previous Address (within the last 3 years) |
| Street Address: |
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| City: |
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Zip:
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| Phone: |
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Drivers License Information (* indicates required fields) |
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| * Drivers License Number: |
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| * State: |
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| * Expiration: |
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Driving Violations (List all in last 3 years) |
| Date1: |
Violations:
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| Date2: |
Violations:
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| Date3: |
Violations:
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Automobile Accidents (List all in last 3 years) |
| Date1: |
Accidents:
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| Date2: |
Accidents:
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| Date3: |
Accidents:
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| By sending this form I understand that my driving record will be verified by the Department of Motor Vehicles. |
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Tell Us About Yourself (* indicates required fields) |
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| Position Appling for: |
EMT
EMTI
AEMT
MVO |
| EMT/AEMT Certification Number: |
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| Expiration: |
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| Number of full time Years Experience: |
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| Have you ever worked for us in the past? |
Yes
No |
| If yes, Reason for leaving: |
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| Are you currently employed? |
Yes
No |
| If yes, By whom? |
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| Are you referred by a current employee of the company? |
Yes
No |
| If yes, By whom? |
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| May we contact any of your present employers? |
Yes
No |
| May we contact any of your previous employers? |
Yes
No |
| Have you ever been convicted of a felony? |
Yes
No |
| If yes, or pending specify: |
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| Are you a US citizen/permanent resident? |
Yes
No |
| If no, do you have a working permit? |
Yes
No |
| Have you served in the US military services? |
Yes
No |
| If yes, branch: |
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| Discharge date/Reason |
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Personal references (Minimum 3 not relatives) |
| Reference Name 1: |
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| Address: |
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| City: |
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Zip:
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| Phone: |
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| Reference Name 2: |
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| Address: |
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| City: |
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Zip:
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| Phone: |
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| Reference Name 3: |
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| Address: |
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| City: |
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Zip:
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| Phone: |
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Previous Employment (* indicates required fields) |
| If employed, start with your current employer and retrace your employment history |
| Company Name 1: |
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| Phone: |
ext:
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| Address: |
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| City: |
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Zip:
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| Employed: |
From:
To:
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| Job Title: |
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| Start Salary: |
Last Salary: |
| Name of Supervisor: |
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| Reason for leaving: |
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| Company Name 2: |
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| Phone: |
ext:
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| Address: |
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| City: |
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| State: |
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Zip:
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| Employed: |
From:
To:
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| Job Title: |
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| Start Salary: |
Last Salary: |
| Name of Supervisor: |
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| Reason for leaving: |
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| Company Name 3: |
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| Phone: |
ext:
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| Address: |
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| City: |
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| State: |
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Zip:
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| Employed: |
From:
To:
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| Job Title: |
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| Start Salary: |
Last Salary: |
| Name of Supervisor: |
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| Reason for leaving: |
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Education History (* indicates required fields) |
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| High School Years completed: |
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| City: |
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| Name of School: |
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| Graduated: |
Yes
No |
| Graduated or Professional: |
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| College Years completed: |
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| City: |
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| Name of School: |
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| Graduated: |
Yes
No |
| Graduated or Professional: |
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| Other School Years completed: |
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| City: |
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| Name of School: |
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| Graduated: |
Yes
No |
| Graduated or Professional: |
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| Technical Trade: |
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| Years completed: |
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| City: |
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| Name of School: |
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| Graduated or Professional: |
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| Are you currently in school? |
Yes
No |
| Where? |
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Additional Training |
Please list below all additional courses, or training that you have taken pertaining to your employment with us including but not excluding any professional certifications.
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Emergency Contact Information (* indicates required fields) |
| Please list 2 emergency contacts including first & last name, address, city, state, zip, and relation to you, and all phone numbers available |
| * Contact Name 1: |
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| Phone: |
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| Address: |
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| City: |
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| State: |
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Zip:
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| * Contact Name 2: |
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| Phone: |
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| Address: |
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| City: |
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| State: |
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Zip:
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Necessary Language: |
| If not a united states citizen, do you have the legal right to remain permanently and to work in the united states: |
| Yes
No |
| Employees who work in the ambulance service must drive vehicles and treat, handle, transfer and transport patients. as a result, the job has certain critical functions, which require driving an automobile under stress, and other physicallly demanding tasks. a complete job description and standard operating procedure and guidelines for employees in the ambulance service is available for review upon request by any job applicant. in light of these critical job functions, will you be physically and mentally able to perform the duties of the job(s) for which you are applying? |
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Yes
No |
| if you need some accommodation in order to perform the job-related functions, please indicate what accommodations are necessary in the “additional training” section. please indicate that you are listing necessary accommodations. a physical or mental impairment will not automatically disqualify you from consideration if you can perform the job with a reasonable accommodation. |
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PLEASE READ CAREFULLY |
Application Form Waiver |
| All statements contained in this application are true and complete to the best of my knowledge. I understand that the misrepresentation or omission of facts requested is cause for immediate dismissal, at any time, without any previous notice. I authorize the Parkland Ambulance Service, Inc. to contact any and all of my references for full information, and hereby release Parkland Ambulance Service, Inc. and any persons who respond to its inquiry from any and all liability as a result of such investigations. |
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| I also understand that (1) Parkland Ambulance Service, Inc. is a drug free workplace having a drug and alcohol policy that provides for pre-employment testing, as well as, testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of periodic and random testing under such policy. |
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| I agree to take a physical examination prior to employment and at any time at the request of Parkland Ambulance Service, Inc. and at no personal expense to me, and agree that the examining physician or their representative may disclose the findings to the company or an authorized agent of the company. |
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| I understand that any employment by Parkland Ambulance Service, Inc. will be on a six (6) continuous month or one hundred (100) workday introductory basis. The employer will have the option of using the 6 month or 100 workday probationary period. If employed by the company I agree to abide by its rules and regulations. Further, I understand that my employment can be terminated at any time during the probationary period with or without cause. |
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I agree * |
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| Federal and State laws prohibit discrimination in employment because of sex, age, race, color, religious creed, national origin, ancestry, liability to service in the Armed Forces of the United States or non-job related handicaps. |
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| Parkland Ambulance Service, Inc. is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. |
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| Thank you for completing this application form and for your interest in our business. |
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| A copy of a drivers license, EMT or AEMT is required with this application on the interview day. |
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Application Agreement |
I certify that the information I've provided is the truth and completed to the best of my knowledge, I authorize any investigation regarding the information I've provided in this application, I understand that falsified information regarding this application may result of my termination at any time.
I agree * |
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| Enter text as shown above *
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