Allied | Medstar | Ambulimo - Application for Employment

personal information

Last Name:	First: Middle:
Address:
City:	State: Zip Code:
Home Telephone Number: Other Phone:
Are you at least 18 years of age? If yes, check:

position information Position(s) Applying For: certification information
(List only current certifications - photocopies required at interview)

Certification	Certification Number	Expiration Date	Certifying Agency
EMT
CPR
EVOC
Other

work requirements and general information

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

Do you have a valid Driver's License? If yes, check: Class:

Issued by what State? Driver's License #:

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

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

If yes, explain:

A conviction will not necessarily disqualify you from employment.

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

If yes, explain:

employment history
(List your last three employers or volunteer activities, starting with the most recent.)

Employer:

Job Title:
Start Date:
End Date:

Supervisor:
Salary:
Salary:

Job Description (including duties and responsibilities):

Employer's Telephone #:

May we contact? If yes, check:

Reason for leaving:

II.

Employer:

Job Title:
Start Date:
End Date:

Supervisor:
Salary:
Salary:

Job Description (including duties and responsibilities):

Employer's Telephone #:

May we contact? If yes, check:

Reason for leaving:

III.

Employer:

Job Title:
Start Date:
End Date:

Supervisor:
Salary:
Salary:

Job Description (including duties and responsibilities):

Employer's Telephone #:

May we contact? If yes, check:

Reason for leaving:

military

Branch of Service	Date Began	Date Ended	Rank & Duties	Date Discharged	Location

Explain any gaps in employment:

past employment

Have you ever been...

Yes | No

Disciplined or terminated for reckless driving? |

Placed on probation or terminated for excessive abstenteeism? |

Disciplined or fired for insubordination? |

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? |

If you answered yes to any question above, please explain:

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

qualifications

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.

Name:
Occupation:
Years Known:

Address:

Telephone Number (including area code):

II.

Name:
Occupation:
Years Known:

Address:

Telephone Number (including area code):

III.

Name:
Occupation:
Years Known:

Address:

Telephone Number (including area code):

acknowledgment

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 hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the Company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employmnt will be "at will" and either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment.

If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perfom the job duties.

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 job 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 discharge from this Company.

I hereby authorize the Company to investigate my employment history with former employers 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, and other such inquires. I release the Company and all informants from all liability resulting from such inquiries. I waive all rights to see and 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 empolyment with the Company may be terminated.

I understand that I must pass the three month probationary period before being considered a full time AMBULANCE EXPRESS employee and be eligible for any and all applicable benefits. I understand and agree that during the three month probationary period my employment may be terminated with or without reason and promise to hold AMBULANCE EXPRESS and its representatives harmless for any such action.

Printed Name:

Applicant's Signature:

Date: