Shift Availability

Monday Availability *

Tuesday Availability *

Wednesday Availability *

Thursday Availability *

Friday Availability *

Saturday Availability *

Sunday Availability *

Qualifications

EMT Expiration Date (If Any)

EMT Level

EMT Instructing Agency (If Any)

EMT Certifications Number

EMT Certification Upload (If Any)

Firefighter Expiration Date (If Any)

Firefighter Level

Firefighter Certifications Number

Firefighter Instructing Agency (If Any)

Firefighter Certification Upload (If Any)

CPR Expiration Date (If Any)

CPR Level

CPR Certifications Number

CPR Certification Upload (If Any)

OTHER Certification Expiration Date (If Any)

OTHER Certification Instructing Agency (If Any)

OTHER Certification Level

OTHER Certification Number

Professional References (List 3 people not related to you, whom you've known for more than one year)

Reference 1 Full Name

Reference 1 Phone Number

Reference 1 Years Known

Reference 1 Occupation/Job

Reference 1 Email

How are you affiliated with Reference 1?

Reference 2 Full Name

Reference 2 Phone Number

Reference 2 Years Known

Reference 2 Occupation/Job

Reference 2 Email

How are you affiliated with Reference 2?

Reference 3 Full Name

Reference 3 Phone Number

Reference 3 Years Known

Reference 3 Occupation/Job

Reference 3 Email

How are you affiliated with Reference 3?

Please list employers from the last 7 years, most current first.

Employer 1 Name

Employer 1 Supervisor's Name

Employer 1 Phone Number

Employer 1 Address

Employer 1 Dates of Employment

Reason for leaving Employer 1

Voluntary

Involuntary

Describe reason for leaving Employer 1

May we contact employer 1?

Yes

Employer 2 Name

Employer 2 Supervisor's Name

Employer 2 Phone Number

Employer 2 Address

Employer 2 Dates of Employment

Reason for leaving Employer 2

Voluntary

Involuntary

Describe reason for leaving Employer 2

May we contact employer 2?

Yes

Employer 3 Name

Employer 3 Supervisor's Name

Employer 3 Phone Number

Employer 3 Address

Employer 3 Dates of Employment

Reason for leaving Employer 3

Voluntary

Involuntary

Describe reason for leaving Employer 3

May we contact employer 3?

Yes

Employer 4 Name

Employer 4 Supervisor's Name

Employer 4 Phone Number

Employer 4 Address

Employer 4 Dates of Employment

Reason for leaving Employer 4

Voluntary

Involuntary

Describe reason for leaving Employer 4

May we contact employer 4?

Yes

Employer 5 Name

Employer 5 Supervisor's Name

Employer 5 Phone Number

Employer 5 Address

Employer 5 Dates of Employment

Reason for leaving Employer 5

Voluntary

Involuntary

Describe reason for leaving Employer 5

May we contact employer 5?

Yes

COLLEGE OR UNIVERSITY

College/University Name

College/University Location

Did you graduate College/University?

Yes

College/University Degree/Major

COLLEGE OR UNIVERSITY

Graduate School Name

Graduate School Location

Did you graduate Graduate School?

Yes

Graduate School Degree/Major

Do you have military experience?

Yes

Military Branch

Military Rank

Military Current Status

Military MOS/RATE

THE INFORMATION PROVIDED IN THIS APPLICATION FOR EMPLOYMENT OR DISCLOSED BY ME IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY OMISSIONS OR FALSE OR MISLEADING STATEMENTS I MAKE IN CONNECTION WITH THE APPLICATION PROCESS MAY RESULT IN EXPRESS AMBULANCE DENYING ME EMPLOYMENT OR, IF I AM HIRED, TERMINATING MY EMPLOYMENT.

I UNDERSTAND THAT, IF I AM OFFERED A JOB, EXPRESS AMBULANCE MAY OBTAIN A BACKGROUND CHECK TO EVALUATE MY APPLICATION AND ELIGIBILITY FOR EMPLOYMENT STATUS, TO DETERMINE MY ELIGIBILITY FOR CONTINUED EMPLOYMENT, PROMOTION OR REASSIGNMENT, OR AFTER AN ACCIDENT. THE VERIFICATIONS OR REPORTS THE COMPANY OBTAINS MAY INCLUDE VARIOUS TYPES OF INFORMATION ABOUT ME, SUCH AS A VERIFICATION OF MY SOCIAL SECURITY NUMBER; CURRENT AND PREVIOUS RESIDENCES; EMPLOYMENT AND EDUCATION HISTORY; PROFESSIONAL CERTIFICATIONS/LICENSES; CHARACTER REFERENCES; A CRIMINAL BACKGROUND CHECK; A MOTOR VEHICLE RECORDS CHECK, INCLUDING, BUT NOT LIMITED TO TRAFFIC CITATIONS AND VEHICLE REGISTRATIONS; CREDIT HISTORY; REPORTS FROM AGENCIES REGARDING WHETHER OR NOT I HAVE BEEN EXCLUDED FROM WORKING WITHIN THE HEALTHCARE INDUSTRY (OIG) OR WITH A FEDERAL CONTRACTOR OR SUBCONTRACTOR (EPLS); AND ANY OTHER INFORMATION THAT IS MAINTAINED IN A PUBLIC RECORD. THE REPORTS PROVIDED TO EXPRESS AMBULANCE WILL NOT CONTAIN MEDICAL INFORMATION.

I FULLY UNDERSTAND THAT, IF OFFERED A POSITION WITH EXPRESS AMBULANCE, PRE-EMPLOYMENT DRUG TESTING WILL BE REQUIRED. SUCH TESTING WILL BE DONE AT AN OFFSITE LOCATION OF OUR CHOOSING. ONCE EMPLOYED, RANDOM DRUG TESTING AND TESTING FOR REASONABLE SUSPICION CAN BE ORDERED BY MANAGEMENT AT THEIR DISCRETION. EMPLOYEES INVOLVED IN AN ACCIDENT WHILE ON DUTY WILL ALSO BE SENT FOR POST-ACCIDENT DRUG TESTING AS IS REQUIRED BY LAW. EXPRESS AMBULANCE IS A DRUG FREE COMPANY. A POSITIVE RESULT, REFUSING TO SUBMIT TO A DRUG AND ALCOHOL TEST, OR TAMPERING WITH A TESTING SAMPLE WILL RESULT IN THE DENIAL AND/OR TERMINATION OF EMPLOYMENT.

I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT EXTENDED BY EXPRESS AMBULANCE IS CONTINGENT UPON:

PASSING A PRE-EMPLOYMENT DRUG AND ALCOHOL TEST;
COMPLETION OF THE DISCLOSURE AND CONSENT FOR RELEASE OF INFORMATION FROM AUTHORIZING THE BACKGROUND/CONSUMER REPORT WITH SATISFACTORY RESULTS. (CERTAIN POSITIONS MAY HAVE ADDITIONAL PRE-EMPLOYMENT REQUIREMENTS, WHICH WILL BE DISCUSSED WITH YOU DURING THE APPLICATION PROCESS.)

BY SIGNING BELOW I ACKNOWLEDGE THE INFORMATION HEREIN IS A TERM OF EMPLOYMENT AND RELEASE ANY FACILITY FROM ALL LIABILITY FOR DISCLOSING SUCH INFORMATION TO EXPRESS AMBULANCE.

Today's Date

Applicant Name (Printed)

EXPRESS AMBULANCE COMPANY AND ITS SUBSIDIARIES PROHIBIT DISCRIMINATION ON THE BASIS OF RACE, COLOR, GENDER, SEXUAL ORIENTATION, AGE, RELIGION, DISABILITY, VETERAN STATUS, OR NATIONAL ORIGIN AND WILL COMPLY WITH ALL FEDERAL AND STATE NON DISCRIMINATION, EQUAL EMPLOYMENT OPPORTUNITY AND AFFIRMATIVE ACTION LAWS, ORDERS AND REGULATIONS.