Personal Data |
| First Name*: |
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| Middle Name (or initial): |
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| Last Name:* |
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| Social Security Number*: |
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| Driver's License No.: |
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| State Issued: |
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| Address*: |
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| City*: |
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| State*: |
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| Zip Code*: |
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| Home Phone*: |
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| Email Address*: |
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Job Application Information |
| Position Applied For*: |
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Referred by:
(be specific)
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| Date of Birth (m/d/yyyy): |
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| I am available: |
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Full Time Part Time
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| Have you filed an application for employment with us before?? |
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Yes No
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Education Information |
| Did you graduate from High School or have a G.E.D.? |
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Yes No
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| Do you have EMT-A Training?: |
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Yes No
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| If yes, where did you receive training?: |
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| EMT License #: |
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Do you have Paramedic Training?: |
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Yes No
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| If yes, where did you receive training?: |
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| Paramedic License #: |
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| Please describe any other school or training you have: |
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Military Service Record |
| Have you served in the U.S. Armed Forces? (if no, skip this section): |
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Yes No |
| If so, which branch?: |
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| Military occupational specialty: |
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| Date service started: |
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| Date service ended: |
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| Are you currently in the National Guard or Reserve?: |
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Yes No |
| What branch?: |
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| Rank: |
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| Required to attend: |
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Summer Camp Monthly Drills
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| Status: |
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Active Inactive |
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Employment History
List below your last 3 employers, beginning with the most recent.
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| Employer's Name: |
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| Complete Address: |
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| Phone: |
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| Start Date: |
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| End Date: |
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| Supervisor's Name: |
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| Reason for Leaving: |
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If you have been disciplined for any reason by this employer, discharged or forced to resign, explain the circumstances fully
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| Starting Pay: |
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per
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| Ending Pay: |
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per
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Job Title/ Responsibilities
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| Employer's Name: |
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| Complete Address: |
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| Phone: |
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| Start Date: |
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| End Date: |
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| Supervisor's Name: |
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| Reason for Leaving: |
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If you have been disciplined for any reason by this employer, discharged or forced to resign, explain the circumstances fully
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| Starting Pay: |
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per
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| Ending Pay: |
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per
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Job Title/ Responsibilities
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| Employer's Name: |
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| Complete Address: |
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| Phone: |
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| Start Date: |
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| End Date: |
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| Supervisor's Name: |
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| Reason for Leaving: |
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If you have been disciplined for any reason by this employer, discharged or forced to resign, explain the circumstances fully
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| Starting Pay: |
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per
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| Ending Pay: |
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per
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Job Title/ Responsibilities
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General Information |
| Number of traffic violations in the past 3 years: |
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| Type(s), Date(s) and State(s): |
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| Number of vehicle accidents in the past 3 years: |
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| Date(s) and State(s): |
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| Have you ever been convicted of a crime?: |
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Yes No |
| If yes, explain: |
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An answer of "Yes" to this does not necessitate the rejection of this application.
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| What would you list as your strong points? |
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| What would you list as your weak points? |
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I agree to perform all pre-employment assessments designed to determine my capabilities to comply with the essential job functions associated with the position for which I have applied. I understand that Midwest Medical Services, Inc. d.b.a.
Advance Ambulance is under no obligation to offer an employment opportunity to me and is in no way guaranteeing me
employment based on these pre-employment assessment results. I further agree to release from responsibility and hold
harmless, Midwest Medical Services, Inc. d.b.a. Advance Ambulance, its employees and representatives, for any injuries, adverse or ill results that may occur during my written, practical and physical agility assessments.
I understand that, unless sometime in the future I enter into a specific written employment contract with Advance Ambulance, that the employment relationship between Advance Ambulance and me is freely terminable at will of either party for any lawful reason.
All information given in my employment application is true and correct to the best of my knowledge and belief. Any
misrepresentation or inaccurate information given by me in this application shall be sufficient cause for cancellation of this
application and/or termination after employment.
I hereby authorize Advance Ambulance to investigate any/all references and to secure additional job related information.
I hereby release from liability any company and its persons, corporations and organizations for furnishing such information.
I understand that this application will be given active consideration for only sixty (60) days and that I may thereafter apply again if I wish to receive continued consideration.
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