Employment Application Part 1: Basic InformationPosition applying for:*Please select a job openingEmergency Medical TechnicianEmergency Medical ResponderWheelchair DriverDispatcherCall TakerHours*Full timePart TimePer DiemAre you available to work: Nights Weekends Holidays Name* First Middle Last Email* Phone*Current Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you at least 18 years of age (required to drive ambulances)?*YesNoAre you at least 21 years of age (required to drive wheelchair van)?*YesNoHave you ever worked/volunteered for this organization?*YesNoIf yes, provide dates:Prior PositionReason for leavingDo you have any friends or relatives working/volunteering for Select Ambulance?*YesNoIf so, please list names:Part 2: CertificationsCertification InformationList only current certifications and attach photo copies of certifications to this application using the uploader below.CertificationCertification NumberExpirationStateAgency Upload CertificationsFor each certification listed above, please upload a file or photo Drop files here or Accepted file types: pdf, doc, docx, jpg, png. Part 3: Educational and Training InformationEducationName of SchoolLocationYears Completed Special Training, Skills, or Licenses:EMS/Fire Service related training not listed above:EMS/Fire/Professional Affiliations (not listed under employment):Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for Select Ambulance to know when considering your application:Part 4: U.S Military ServicesDid you ever serve in the U.S. Armed Forces during any war or armed conflict in which the United States was engaged?*YesNoDate of Entry Date Format: MM slash DD slash YYYY Date of Discharge Date Format: MM slash DD slash YYYY Honorable Discharge:YesNoUpload Copy of Honorable DischargeSupply copy of honorable discharge below (DD form 214)Part 5: BackgroundHave you ever been convicted of a crime other than a summary or minor traffic offense?*YesNoIf yes, describe:Are you addicted to the habitual use of intoxicating liquors?*YesNoAre you affiliated with any group whose policies or activities are subversive to the form of government set forth in the Constitution and laws of the United States and the Commonwealth of Pennsylvania*YesNoAre you prevented from becoming lawfully employed in this country because of Visa or Immigration Status?*If hired, an Immigration Form I-9 and proof of citizenship will be needed.YesNoPart 6: Driving InformationThis job requires you to have a valid driver's license and safe driving record and a driving record check will be performed.Do you have a valid driver's license?*YesNoState*License Number*Expires*ClassesRestrictionsHas your driver's license ever been suspended?*YesNoIf yes, provide dates and reasonPart 7: Employment HistoryBeginning with the MOST RECENT, list all jobs including volunteer work, part time employment while in school, military service, self-employment and unemployment for at least the past five (5) years and including at least the last three (3) employers.Part 8: ReferencesList three references; do not use relatives.ReferencesNameRelationshipOccupationPhoneAddressYears Known Part 9: Agreement and Signature - Please read carefully before signingI swear that all of the information contained in this application is true and correct. I understand that all of the information contained in this application is subject to verification by Select Ambulance. The investigation may include contacting prior employers, checking my driving record and criminal record check. I understand that misrepresentation or omission of any facts on this application will cause it to be rejected, or if not discovered until after hire, will subject me to termination. I understand: All applicants offered a position agree to comply with provisions of our Drug and Alcohol policy and understand that violations of the policy will be considered willful misconduct and will result in discipline up to and including termination of employment. All applicants offered a position considered physically demanding or safety sensitive will be required to successfully pass a physical ensuring they can safely perform the position being offered. All applicants offered a position that requires driving will be required to have a valid driver’s license and a safe driving record. All applicants offered a position may, as necessary, be required to successfully complete a criminal background check and child abuse history clearance. All applicants are required at time of application to review the position they are applying and agree they are able to meet all aspects of the position. I further understand that as a condition of employment I will be required to successfully pass a drug screening test. If an offer of employment is made to me it will be contingent upon my taking and passing a complete job-related physical examination. I further understand that nothing in this application or in the granting of conduction of an interview or tests is intended to create an employment contract of any kind. No promises regarding employment have been made to me and I understand that no such promise would be binding upon the management of Board of Directors of Select Ambulance.Confirm* I have read and agree to the terms above.Signature* Employment HistoryEmployer NameAddressStart DateEnd DateJob TitleMajor DutiesImmediate Supervisor NameImmediate Supervisor PhoneNext Higher SupervisorStarting Salary Per HourCurrent SalaryReason For LeavingMay We Contact Your Present Employer?Add EmployerRemove Employer Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.