Employment Opportunities

Our company is an equal opportunity employer and will consider all applicants equally without regard to their race, sex, age, color, religion, national origin, veteran status or any disability as provided in the Americans With Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

PERSONAL:

Full Name:

Address:

City:

State:

Zip:

Social Security #:

Home #:

Pager#:

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States?

Have you ever been convicted of a crime (excluding minor traffic violations) including driving under the influence of alcohol or drugs?

If yes, state the offense, location, date, and disposition:

Do you have the ability to work overtime if it is required by the job for which you are applying?
If no, please explain:

Drivers License #:
State:
Expires:

EMPLOYMENT DESIRED

Are you seeking

Position applied for:
Salary desired:
If you are applying for Basic EMT position, are you at least 24 years old?

Date available to start?

How did you learn about our company?

LEVEL OF TRAINING (Include Certification or License Number)

Level:
Cert. or Lic #
Expires:

Are you currently certified in the following? (If yes please list level, cert.# and expiration date)

Specialty	Level	Cert#	Expiration Date
BCLS:
ACLS:
PALS:
BTLS:
PHTLS:
PLS:
Other:
Other:

EDUCATION

High School:

Address:

Date Graduated: Date of GED:

College:

Address:

Area of Study: Date of Completion:

Medical Training:

Address:

Area of Study: Date of Completion:

Medical Training:

Address:

Area of Study: Date of Completion:

If you did not graduate, why did you leave high school or college?

Are you planning to pursue further studies? If so, when and what courses?

List and describe any other School or Specialized Training:

WORK HISTORY

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
PLEASE GIVE MONTH AND YEAR DO NOT REFERENCE YOUR RESUME

Name of Employer1:

Address:

City: State: Zip:

Phone #: Supervisor:

Dates employed: From (mm/dd/yy) to

Pay: Start End

Reason for leaving?

Name of Employer2:

Address:

City: State: Zip:

Phone #: Supervisor:

Dates employed: From to

Pay: Start End

Reason for leaving?

Name of Employer3:

Address:

City: State: Zip:

Phone #: Supervisor:

Dates employed: From to

Pay: Start End

Reason for leaving?

Name of Employer4:

Address:

City: State: Zip:

Phone #: Supervisor:

Dates employed: From to

Pay: Start End

Reason for leaving?

Name of Employer5:

Address:

City: State: Zip:

Phone #: Supervisor:

Dates employed: From to

Pay: Start End

Reason for leaving?

SUPPLEMENTAL EMPLOYMENT INFORMATION

If you worked in any of your previous positions under another name, please give that name(s) below:
(For references checking purposes)

Name: @Company

Are you presently employed? If so, may we contact your present employer?

Have you ever been fired, or asked to resign, from a job?
If yes, please explain:

Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness?

If yes, please explain:

What languages do you speak fluently?

Do you have any experience in mobile intensive care transports?

REFERENCES

Give three references, not relatives, or former employers.

Name:
Address:
Phone #:
Occupation:

MILITARY

Have you ever served in the military?

Service Branch: Date entered:

Dated Separated: Final Rank:

CREDIBILITY/RELIABILITY:

Would you be willing and able to perform all of the tasks required by the job you are applying for?
If No, which tasks?

Have you ever filed any type of fraudulent claim against any of your present or past employers?

If yes, please explain:

Will you abide by the safety rules of this company?

Have you ever been disciplined for violating company safety rules or regulations?
If yes, please explain:

How many days of work (or school) have you missed in the last two years?

How many times have you been late for work (or school) in the last two years?

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during interviews may be grounds for my immediate discharge.

I hereby authorize Advanced Ambulance Service, Inc. and any of its related companies, subsidiaries, or agents to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their reveling any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I hereby authorize Advanced Ambulance Service, Inc. and any of its related companies, subsidiaries, or agents to receive any driving and criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

I agree that, if employed, I will abide by all of the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is "at-will" and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.

(Digital) Signature: Date: