EMPLOYMENT APPLICATION (Non-Clinical)
Name: _______________________________________ Social Security #:_________________ Today's Date:______________________
Last First M.I.
Home Phone:_______________________________________ Work Phone:__________________________________________________
Current Address: ________________________________________________________________________________________________
(physical & mailing) Street City State Zip
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment
contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form
are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive
consideration without discrimination because of sex, race, religion, age, creed, national origin, pregnancy, military status or the presence of disabilities.
Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. Depending on company
policy and the needs of the job, you may be required to complete a medical history form and may be required to be examined by a medical
professional designated by the company.
For which position are you applying?___________________________________________________________________________________
What date can you start?___________________________ Which would you prefer? ___ Full-time ___ Part-time
For which schedules are you available? ___ Weekdays ___ Weekends ___ Evenings ___ Nights
List states and counties of residence for the past seven years.________________________________________________________________
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? ___ Yes ___ No
(Proof of citizenship or immigration status will be required upon employment.)
Have you been convicted of a misdemeanor, felony and/or served time in the past seven years? If so, please describe below.
(In accordance with company policy this information will be reviewed for job relatedness and time since last conviction.)
_________________________________________________________________________________________________________________
Incident City/State Charge
If applying for EMT position:
Do you have the appropriate valid drivers license? DL#:______________________________________ State:________________________
Have you had any driving tickets or accidents in the last five (5) years? Please describe: ____________________________________________ ________________________________________________________________________________________________________________
___ Yes ___ No Have you been given a job description or had the requirements of the job explained to you?
___ Yes ___ No Do you understand these requirements?
___ Yes ___ No Can you perform the requirements of this job with or without reasonable accommodation?
EMT Certifications ( if applicable)
Date of Certification State School Number Expiration Date
EMT-D
EDUCATION Name City/State Dates Graduate?
Other
EMPLOYMENT REFERENCES Your application will not be considered unless every question in this section is answered.
Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.
MOST RECENT EMPLOYER ___ Yes ___ No Are you currently working for this employer? If yes, may we contact? ______
_______________________________________ ______________________________________ _______________________________
Company Name City / State Phone Number
To From ____________________________________ ___________________________________________
Dates Employed Job Title Supervisor Name
Duties
Per ________________________________________________________________________________________
Salary (Hour, Week, Month) Reason for Leaving
SECOND MOST RECENT EMPLOYER
________________________________________ _____________________________________ _____________________________
Company Name City / State Phone Number
To From ___________________________________ __________________________________________
Dates Employed Job Title Supervisor Name
_______________________________________________________________________________________________________________
Duties
Per _______________________________________________________________________________________
Salary (Hour, Week, Month) Reason for Leaving
THIRD MOST RECENT EMPLOYER
_________________________________________ _____________________________________ _____________________________
Company Name City / State Phone Number
To From _____________________________________ _________________________________________
Dates Employed Job Title Supervisor Name
_______________________________________________________________________________________________________________
Duties
Per
Salary (Hour, Week, Month) Reason for Leaving
REFERENCES Include only individuals familiar with your work ability. Do not include relatives.
Name Address / Phone Years Known / Relationship
CERTIFICATION AND RELEASE I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature Date
Revised: April 7, 2003