EMPLOYMENT APPLICATION



POSITION APPLYING

APPLICANT INFORMATION

YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

Equal Employment Opportunity:While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin,race and sex for planning and reporting purpose only. This information is optinal and failure to provide it will have no affect on your application for employment.

EMPLOYMENT HISTORY

LIST MOST RECENT EMPLOYMENT FIRST. INCLUDE SUMMER OR TEMPORARY JOBS. BE SURE ALL YOUR EXPERIENCE OR EMPLOYERS RELATED TO THIS JOB ARE LISTED HERE, IN THE SUMMARY FOLLOWING THIS SECETION. NO MORE THAN 10 YEARS HISTORY RECOMMENDED.

EMPLOYER NAME: POSITION TITLE & DUTIES:
ADDRESS:
SUPERVISOR NAME: TELEPHONE: START PAY HOUR: END PAY HOUR:
START DATE: END DATE: REASON FOR LEAVING:



AVAILABLITY

DAY: NOT AVAILABLE: PARTIALLY AVAILABLITY: FULL AVAILABLITY:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

OFFICE/TECHNICAL SKILLS

EDUCATION

TYPE OF SCHOOL NAME CITY,STATE YEARS COMPLETED MAJOR COMPLETED
HIGH SCHOOL
COLLEGE
BUS. OR TRADE SCHOOL
PROFESSIONAL SCHOOL

LICENSES/CERTIFICATION INFORMATION

LICENSE/CERITICATION ISSUING STATE/INSTITUTION LICENSE NUMBER (IF APPLICABLE) EXP. DATE
STATE EMT CERTIFICATION
STATE PARAMEDIC CERTIFICATION
NREMT CERTIFICATION
EMD (EMERGENCY MEDICAL DISPATCHER)
CPR
ACLS
PALS
EVOC
RN
BTLS
DO YOU CURRENTLY HOLD ANY INSTRUCTOR LICENSE?
IS YES PLEASE LIST:
OTHER:

MILITARY

PROFESSIONAL

REFERENCES

NAME ADDRESS TELEPHONE OCCUPATION YEARS KNOWN

EMERGENCY CONTACT

APPLICANT’S STATEMENT AND AGREEMENT

I hereby, certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material facts on this application of on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby, authorize Firstmed Ambulance Services, Inc. to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to Firstmed Ambulance Services, Inc. all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Firstmed Ambulance Services, Inc., my former employers and all other persons, corporation, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I hereby, agree to submit binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that if I am hired by Firstmed Ambulance Services, Inc., that all disputes that cannot be resolved by informal internal resolution, which might arise out of my employment with Firstmed Ambulance Services, Inc., whether during or after the employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.

I understand that nothing contained in the application, or conveyed during any interview, which may be granted or during my employment, if hired, is intended to create an employment contract between me and Firstmed Ambulance Services, Inc. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Firstmed Ambulance Services, Inc., and that no promises or representations contrary to the foregoing are binding on the Firstmed Ambulance Services, Inc. unless made in writing and signed by Firstmed Ambulance Services, Inc. designated representative.