Employment Application

Part 1: Basic Information

Position applying for:*

Hours*

Full time
Part Time
Per Diem

Are you available to work:

Nights
Weekends
Holidays

Name*

First Middle Last

Email*

Phone*

Current Address*

Street Address City State ZIP Code

Are you at least 18 years of age (required to drive ambulances)?*

Yes
No

Are you at least 21 years of age (required to drive wheelchair van)?*

Yes
No

Have you ever worked/volunteered for this organization?*

Yes
No

If yes, provide dates:

Prior Position

Reason for leaving

Do you have any friends or relatives working/volunteering for Select Ambulance?*

Yes
No

If so, please list names:

Part 2: Certifications

Certification Information

List only current certifications and attach photo copies of certifications to this application using the uploader below.

Certification	Certification Number	Expiration	State	Agency

Upload Certifications

For each certification listed above, please upload a file or photo

Drop files here or

Part 3: Educational and Training Information

Education

Name of School	Location	Years 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 Services

Did you ever serve in the U.S. Armed Forces during any war or armed conflict in which the United States was engaged?*

Yes
No

Date of Entry

Date of Discharge

Honorable Discharge:

Yes
No

Upload Copy of Honorable Discharge

Supply copy of honorable discharge below (DD form 214)

Part 5: Background

Have you ever been convicted of a crime other than a summary or minor traffic offense?*

Yes
No

If yes, describe:

Are you addicted to the habitual use of intoxicating liquors?*

Yes
No

Are 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*

Yes
No

Are 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.

Yes
No

Part 6: Driving Information

This 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?*

Yes
No

State*

License Number*

Expires*

Classes

Restrictions

Has your driver's license ever been suspended?*

Yes
No

If yes, provide dates and reason

Part 7: Employment History

Beginning 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: References

List three references; do not use relatives.

References

Name	Relationship	Occupation	Phone	Address	Years Known

Part 9: Agreement and Signature - Please read carefully before signing

I 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 History

Employer Name

Address

Start Date

End Date

Job Title

Major Duties

Immediate Supervisor Name

Immediate Supervisor Phone

Next Higher Supervisor

Starting Salary Per Hour

Current Salary

Reason For Leaving

May We Contact Your Present Employer?