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Employment Application – Applicant Name

Position Applying For*

First Name

Last Name

Phone

Email Address

Applicant Address

Present Address*

Address line one

Address line two

City

State

Postal Code

Permanant Address

Address line one

Address line two

City

State

Postal Code

Are you able to perform the essential functions of the position for which you are applying for without accommodations?*

Yes

Are you legally eligible for emplyment in the U.S.?*

(Section 1 of the form 1-9 must be completed no later than the first day of the employemnt.”first day of the employment” referes to the first day of work in exchange for pay or other remuneration. Visit uscis.gov for details.)

Yes

Are you at least 18 years old?*

(if under 18, hire is subject to verification that you are of minimum legal age)

Yes

If necessary for the job, I am able to:*

	YES	NO
	YES	NO
Work overtime?
Provide a valid driver’s license?

If yes fill out the following: issuing State & Type:

State / Type

Have you ever worked with Firstmed Ambulance?*

Yes (must state when)

Write here

Do any of your friends or relatives work here?*

Yes (must state their full names)

Write here

Date available to start work:*

Select Date ×

Employment History

Availability

Total Desired Hours Per Week*

Number of Hours

Would you Prefer*

Days

Nights

Weekends

Office / Technical Skills

Keyboards-WPM*

Words per minute

10 Key-KPH*

Keystrokes per hour

Education

	Name	City / State	Years Completed	Major Completed
	Name	City / State	Years Completed	Major Completed
High School	Name	City / State	Years Completed	Major Completed
College	Name	City / State	Years Completed	Major Completed
Bus. or Trade School	Name	City / State	Years Completed	Major Completed
Professional School	Name	City / State	Years Completed	Major Completed

Licenses / Certification Information

	Issuing State/ Institution	License Number (if applicable)	Exp. Date
	Issuing State/ Institution	License Number (if applicable)	Exp. Date
State EMT Certification	Issuing State/ Institution	License Number (if applicable)	Exp. Date
State Paramedic Certification	Issuing State/ Institution	License Number (if applicable)	Exp. Date
NREMT Certification	Issuing State/ Institution	License Number (if applicable)	Exp. Date
EMD (Emergency Medical Dispatcher)	Issuing State/ Institution	License Number (if applicable)	Exp. Date
CPR	Issuing State/ Institution	License Number (if applicable)	Exp. Date
ACLS	Issuing State/ Institution	License Number (if applicable)	Exp. Date
PALS	Issuing State/ Institution	License Number (if applicable)	Exp. Date
EVOC	Issuing State/ Institution	License Number (if applicable)	Exp. Date
RN	Issuing State/ Institution	License Number (if applicable)	Exp. Date
BTLS	Issuing State/ Institution	License Number (if applicable)	Exp. Date

Do you currently hold any instructor license?

Yes (please list)

Write here

Military / Professional

Are you a Veteran?

Yes (Duty / Specialized Training)

Write here

Has your professional license and/or certification ever been suspended or revoked?

Yes (please explain)

Write here

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

Yes (please explain)

Write here

Has any administrative action been taken by any governing regulatory agency regarding your professional license/certification?

Yes (please explain)

Write here

References

	Name	Address	Telephone	Occupation	Years Known
	Name	Address	Telephone	Occupation	Years Known
1	Name	Address	Telephone	Occupation	Years Known
2	Name	Address	Telephone	Occupation	Years Known
3	Name	Address	Telephone	Occupation	Years Known

Emergency Contact

In case if accident or illness, name:

Full Name

Relation*

Relation

Address*

Address

Applicants 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.

By initialing here, I confirm I have read this paragraph. I hereby agree to submit to mediation all disputes and claims arising out of the submission of this application. In addition, should mediation fail, I then agree to submit any such claims to binding arbitration and to waive any and all rights to a jury trial or to bring or participate in any class or collective action based upon such claims. If hired by this company, I agree that all disputes, whether on the part of the employer or the employee, that cannot be resolved by informal resolution, or then by mediation, which arise out of my employment with the company, will be submitted to binding arbitration. I agree that I will waive all rights to jury trial and that all relevant costs of the Arbitrator shall be paid by the employer. I agree that all claims subject to this Agreement must be pursued on an individual basis only. I agree to waive my right to commence, or be a party to, any class, collective or representative action or to bring jointly or collectively any claim. I shall have an unfettered right to opt-out of this class action waiver as stated in this part within 30 days of my agreement to accept it, and should I opt-out, said provision shall not be applicable to me. However, such an opt-out decision must be in writing and presented to the HR department or some other management personnel.

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.

Applicants Signature

I Accept signing this Agreement Electronically.

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Start your Career Today!

Employment Application – Applicant Name

Applicant Address

Employment History

Availability

Office / Technical Skills

Education

Licenses / Certification Information

Military / Professional

References

Emergency Contact

Applicants Statement and Agreement

Applicants Signature

Your form has been submitted

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