EMS Employment Application

Contact & Background Information

LAST NAME: *
FIRST NAME: *
MIDDLE INITIAL:
 
EMAIL ADDRESS: *
PHONE NUMBER:
ex 5075551111		 *
 
ADDRESS: *
CITY: *
STATE/PROVINCE: *
POSTAL CODE: *

Position(s) desired:
Some of our positions require regional and national traveling. Are you willing to travel? Yes
No
What type of position are you seeking?
(Check all that apply.) 		Full-time
Part-time
Temporary
Have you worked for EMS in the past? Yes
No
If yes, please explain:
Have you been convicted of any crimes in the last 7 years? (A conviction will not automatically bar employment) Yes
No
If yes, please explain:
How did you hear of this opening? Internet
Friend
Newspaper
Ad
Other:

Education History

High
School		 School Name
Location
Years Completed
 
College School Name
Location
Years Completed
Courses Studied
Degrees Earned
 
Technical
Training		 School Name
Location
Years Completed
Courses Studied
Degrees Earned
 
Other

Employment History

(Start with present or last employer.)
  Employer
Address
Position/Title
Duties
Starting Date Click to Pick the date
Ending Date Click to Pick the date
Salary/Wage
Reason for Leaving
 
  Employer
Address
Position/Title
Duties
Starting Date Click to Pick the date
Ending Date Click to Pick the date
Salary/Wage
Reason for Leaving
 
  Employer
Address
Position/Title
Duties
Starting Date Click to Pick the date
Ending Date Click to Pick the date
Salary/Wage
Reason for Leaving

References

  May we contact your past or present employer? Yes
No
Supervisor or Contact
Phone Number
ex 5075551111

References excluding relatives and former employers:
  Name
Title
Address
Phone  ex 5075551111
 
  Name
Title
Address
Phone  ex 5075551111
 
  Name
Title
Address
Phone  ex 5075551111
 

Other Information

Summarize any additional job-related skills, licenses, certificates, and/or other qualifications you may have:

I certify that the information contained in this application is true and complete to the best of my knowledge and understand that any false or inaccurate information on this application will render my application invalid and will lead to my termination if I am hired based upon these false statements.*

 Date: *      Initials: *