Employment Form – Medic One Ambulance

Select your Application Region *

Select the desired Employment Type *

Full Time
Part-time

PERSONAL INFORMATION

Name *

First

Last

Email *

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Are you 18 years of age? *

Yes
No

Date Available to Start

How did you find out about this position?

List any relatives or friends working/volunteering at Medic One?

POSITION INFORMATION

Position Applying For:

Have you ever worked or volunteered for this organization?

Yes
No

If so, select date last worked

Prior position(s) here:

Reason(s) for leaving:

CERTIFICATION INFORMATION

Check all current certifications. Note: Photocopies will be required at interview.

Certification(s)

WORK REQUIREMENTS - GENERAL INFORMATION

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

Yes
No

Do you have a valid Driver’s License?

Yes
No

Class?

Issued by what State?

Driver’s License #:

List all moving violations (convictions), accidents, and any suspensions or revocations of your license in the last 5 years:

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

Yes
No

A conviction will not necessarily disqualify you from employment.

If yes, explain:

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

Yes
No

If yes, explain:

EMPLOYMENT HISTORY

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

Add First Employment History?

Yes
No

Employer:

Job Title:

Manager:

Start Date:

Starting Salary:

End Date:

Ending Salary:

Job Description (including duties and responsibilities):

Employers Telephone #:

May we contact?

Yes
No

Reason for leaving:

Add Second Employment History?

Yes
No

Second Employer:

Job Title:

Manager:

Start Date:

Starting Salary:

End Date:

Ending Salary:

Job Description (including duties and responsibilities):

Employers Telephone #:

May we contact?

Yes
No

Reason for leaving:

Add Third Employment History?

Yes
No

Third Employer:

Start Date

Starting Salary:

End Date:

Ending Salary:

Job Description (including duties and responsibilities):

Employers Telephone #:

May we contact?

Yes
No

Reason for leaving:

MILITARY HISTORY

Have you ever served in the Military or other branch of service?

Yes
No

Branch of Service:

Date Began:

Date Ended:

Rank & Duties:

Date Discharged:

Location:

Explain any gaps in employment:

PAST EMPLOYMENT

Have you ever been (select all that apply):

Disciplined or terminated for reckless driving?
Placed on probation or terminated for excessive absenteeism?
Disciplined or fired for violation of safety rules?
Disciplined or fired for assault or fighting?
Disciplined or fired for harassment?
Disciplined or fired for patient abuse?
Disciplined or fired for alcohol or drug related activity at work?

An answer of Yes for any of the above questions will not necessarily disqualify you from employment.

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

EDUCATION AND TRAINING

Did you attend high school?

Yes
No

School Name:

Address:

Years completed:

Did you graduate?

Yes
No

If not, highest grade completed:

Have you receive your GED?

Yes
No

Did you attend college?

Yes
No

Name of College:

Address:

Years completed:

Did you graduate?

Yes
No

If not, highest year completed:

Degree:

Major:

Add additional college history?

Yes
No

Name of Other College:

Address:

Years completed:

Did you graduate?

Yes
No

If not, highest year completed:

Degree:

Major:

Did you attend a technical school?

Yes
No

Name:

Address:

Years completed:

Did you graduate?

Yes
No

If not, highest year completed:

Certificate:

Certificate Expires:

License:

License Expires:

Do you have any other schooling or training to add?

Yes
No

Name:

Address:

Years completed:

Did you graduate?

Yes
No

If not, highest year completed:

Certificate:

Certificate Expires:

License:

License Expires:

OTHER:

EMS/FIRE SERVICE RELATED TRAINING NOT LISTED ABOVE:

EMS/FIRE/PROFESSIONAL AFFILIATIONS:

(list any affiliations not 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:

References

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

Add first professional reference?

Yes
No

First Reference Name:

First Reference Address:

Address Line 1

Address Line 2

City

State

Zip Code

First Reference Occupation:

First Reference Years Known:

First Reference Telephone Number (including area code):

Add second reference?

Yes
No

Second Reference Name:

Second Reference Address:

Address Line 1

Address Line 2

City

State

Zip Code

Second Reference Occupation:

Second Reference Years Known:

Second Reference Telephone Number (including area code):

Add third reference?

Yes
No

Third Reference Name:

Third Reference Address:

Address Line 1

Address Line 2

City

State

Zip Code

Third Reference Occupation:

Third Reference Years Known:

Third Reference Telephone Number (including area code):

Add first personal reference?

Yes
No

Personal Reference Name:

Personal Reference Address:

Address Line 1

Address Line 2

City

State

Zip Code

How they know you:

Years known:

Telephone Number (including area code):

Add second personal reference?

Yes
No

Second Personal Reference Name:

Second Personal Reference Address:

Address Line 1

Address Line 2

City

State

Zip Code

How they know you:

Years known:

Telephone Number (including area code):

Acknowledgement *

Yes, I have read & agree.
No. I do not agree.

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 I become a employee. I recognize that completion of this application does not mean that I will be accepted as an employee and does not obligate the Company to accept me as an employee. Applications will remain active for six months, after which time re-application will be necessary. If accepted for employment, I agree to abide by all rules, regulations and policies established by the Company and its officers and other persons in charge. I understand that, if accepted as an employee, my employment will be "at will" and either I or the Company can terminate the employment relationship at any time for any reason or no reason and without prior notice. This application is not an agreement or a contract for employment.

If offered employment and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the duties of employment.

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 employment 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 termination of my employment with the Company.

I hereby authorize the Company to investigate my employment history with former employers and volunteer organizations 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, elder abuse clearance check, FBI background 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.

Type Your Name *

Employment Application

Medic One considers applications for employment/membership without regard to race, color, national origin, ancestry, religion, sex age, disability, political belief, military service, citizenship or any other protected class. Medic One IS A DRUG_FREE WORKPLACE.

Complete all required fields. By clicking SUBMIT, your information will be sent for consideration.

PERSONAL INFORMATION

POSITION INFORMATION

CERTIFICATION INFORMATION

WORK REQUIREMENTS - GENERAL INFORMATION

EMPLOYMENT HISTORY

MILITARY HISTORY

PAST EMPLOYMENT

EDUCATION AND TRAINING

References

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