Employment

Personal Information

Full Name

Phone

Email

Position Applying for

Are you currently an EMT, EMT-I or EMT-P? If so, please provide your EMT number and expiration date.

Date you can start work

Do you have a High School Diploma or GED?

Yes

No

Position Information

Check all that you are willing to work

Hours

Full Time

Part Time

Time of Day

Days

Evenings

Nights

I'm willing to work

Weekdays

Weekends

Status

Regular

Temporary

Are you authorized to work in the U.S. on an unrestricted basis?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Please Explain

Can you perform these essential functions of the job with or without reasonable accommodation?

Yes

No

Please explain

Qualification

Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.

School Name

Degree

Address/City/State

Add Another School?

Yes

No

School Name

Degree

Address/City/State

Add Another School?

Yes

No

School Name

Degree

Address/City/State

Special Skills

List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc.

References

Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don’t have three professional references, then list personal, unrelated references.

1. Name

Address/City/State

Phone

Relationship

2. Name

Address/City/State

Phone

Relationship

3. Name

Address/City/State

Phone

Relationship

Work History

Start with your present or most recent employment and work back.

Job Title

Company Name

Supervisor's Name

Phone Number

Duties

Start Date

End Date

Reason for Leaving

May we contact employer?

Yes

No

Add Another Job?

Yes

No

Job Title

Company Name

Supervisor's Name

Phone Number

Duties

Start Date

End Date

Reason for Leaving

May we contact employer?

Yes

No

Add Another Job?

Yes

No

Job Title

Company Name

Supervisor's Name

Phone Number

Duties

Start Date

End Date

Reason for Leaving

May we contact employer?

Yes

No

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.

I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party

Signature

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Employment Opportunities

Requirements

Personal Information

Position Information

Qualification

Special Skills

References

Work History

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