1 Non- Profit Air a n d Ground Ambulance S ervices Thank you for applying for employment with Mercy Flights. Please complete the enclosed application and attached documentation. Below you will find a list of documents that you must provide with your completed application. Non-Medical Candidates Affirmative Action Voluntary Information, Self Identification of Disability and Veteran's Pre-Offer forms Any certifications or licenses specific to the job position Medical Candidates Affirmative Action Voluntary Information, Self Identification of Disability and Veteran's Pre-Offer forms Copy of Oregon EMT certificate or RN license Other current certificates (i.e. ACLS, CPR, PHTLS/BTLS, PALS, etc.) Oregon Driver s License Pilot Candidates Affirmative Action Voluntary Information, Self Identification of Disability and Veteran's Pre-Offer forms Other certificates including pilots license Oregon Driver s License Qualified applicants will be invited to participate in an assessment center which may consist of the following elements: Written test Oral interview Practical assessment Applicants selected from the assessment center will be required to pass a background investigation. The following elements are included in a background investigation: Criminal background check Medicare/Medicaid restrictions (positions involving billing or patient contact) Former employers References Credit check (for fiscally sensitive positions) DMV record check for positions that require operation of motor vehicles The following conditions must be met after a tentative job offer is accepted but prior to first day of employment: Signed alcohol and drug addiction free form Pre-employment drug screen Successful completion of a medical examination and physical ability test (for positions with requirement) Tobacco free during work hours; on company property; company business agreement Thank you again for applying with Mercy flights, please return your application required documentation to Shanon Harvey either by at by fax (541) or deliver to Mercy Flights, 2020 Milligan Way, Medford, OR If you have any questions about the application process, please contact us at the number below. Sincerely, Shanon Harvey, PHR Human Resources (541) Mercy Flights is an equal opportunity employer. Mercy Flights considers all applicants for positions without regard to race, color, religion, sex, national origin, age, citizenship, mental or physical disabilities, sexual orientation, military service or any other similarly protected status. Mercy Fli g hts, I n c M i lligan Way M e dford O R P h : F x : g hts. com
2 Application for Employment Please Print or Type Equal access to programs services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. This application must be completed and all applicable questions answered. Do not refer to a resume in a question. Position you are applying for: Date of application: / / Referral Source: Advertisement Employee Relative Government Employment Agency Walk-in Private Employment Agency Other Name: Social Security # Last First Middle Address: Street City State Zip Code Telephone ( ) - Mobile/Pager ( ) - Other: ( ) - If necessary, the best time to call you at home is: May we contact you at work? Yes No If yes, work number and best time to call ( ) - am pm Have you submitted an application here before? Yes No If yes, give date(s) and position(s) Have you ever been employed here before? Yes No If yes, give dates: From: / / To: / / Are you legally eligible for employment in this country? Yes No Date available for work: / / Type of employment desired Full-Time Part-Time Casual Seasonal Will you relocate if the job requires it? Yes No Will you travel if the job requires it? Yes No Are you able to meet the attendance requirements of the position? Yes No Will you work overtime if required? Yes No If no, please explain: Have you ever pled guilty or no contest to, or been convicted of a crime? Yes No If yes, provide date(s) and details: ANSWERING YES TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT Drivers license number: State: EMT/RN # State: Skills and Qualifications Word Excel MS Office Power Point Internet Type Words per minute Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
3 AN EQUAL OPPORTUNITY EMPLOYER Employment History Starting with your most recent employer, provide the following information for the last 10 years. Reason for Leaving Reason for Leaving Reason for Leaving Reason for Leaving
4 Reason for Leaving Educational Background (if job related) Starting with your most recent school attended, provide the following information Number of years School (include City and State) Achieved Completed GED Diploma Degree GED Diploma Degree GED Diploma Degree GPA Class Rank Major Minor References List name and telephone number of three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you. Number of Name Title Relationship to You Telephone Years known Additional Information List professional, trade, business or civic associations and any offices held. EXCLUDE MEMBERSHIPS WHAT WOULD REVEAL RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, CITIZENSHIP, AGE, MENTAL OR PHYSICAL DISABILITIES, VETERAN/RESERVE NATIONAL GUARD OR ANY OTHER SIMILARLY PROTECTED STATUS. Organization Offices Held List special accomplishments, publications, awards, etc. EXCLUDE MEMBERSHIPS WHAT WOULD REVEAL RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, CITIZENSHIP, AGE, MENTAL OR PHYSICAL DISABILITIES, VETERAN/RESERVE NATIONAL GUARD OR ANY OTHER SIMILARLY PROTECTED STATUS. List any additional information you would like us to consider regarding your qualifications for this job. EXCLUDE MEMBERSHIPS WHAT WOULD REVEAL RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, CITIZENSHIP, AGE, MENTAL OR PHYSICAL DISABILITIES, VETERAN/RESERVE NATIONAL GUARD OR ANY OTHER SIMILARLY PROTECTED STATUS.
5 Application Statement PRE-ASSIGNMENT PHYSICAL/TESTING NOTICE Mercy Flights, Inc., is committed to maintaining a drug-free work environment. All candidates to whom a contingent offer of employment has been made, are required to complete a medical history form/examination, including testing for drugs and alcohol, and may include a job related physical ability test. These tests are administered by a physician or designee, by an outside company and are paid for by Mercy Flights. Employment is contingent upon a candidate s submission to and successful completion of the medical exam and tests. APPLICANT S ACKNOWLEDGEMENT I agree to undergo the pre-assignment physical, drug/alcohol test and if required for the position, a physical ability test. I understand that the results of such testing will be disclosed to Mercy Flights hiring personnel, and others with a need to know, or as required by law. I understand that if I refuse to consent to testing, fail to provide a urine sample when requested, provide a false or tampered urine sample, or fail to successfully complete the physical and medical examination, I will be terminated. I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, Mercy Flights, Inc., its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer s service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant: Date: / / Typing your FULL name in the above signature line constitutes a legal signature.
6 Affirmative Action Voluntary Information Completion of information below is voluntary Mercy Flights, Inc. considers all applicants for positions without regard to race, color, religion, sex, national origin, age, citizenship, mental or physical disabilities, sexual orientation, military service or any other similarly protected status. As an employer/government contractor, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out this Affirmative Action Voluntary Information form. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment. This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment. Name: Date : Position(s) applied for Gender Male Female Please mark one of the following: Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. Race missing or unknown - Applies to Applicants only, where a resume or application that is screened is received without any racial or ethnic identification and no further contact is made with the applicant. How did you hear about our opening? Walk in Internet Employee School State Employment Agency Private Employment Agency Advertisement: Other: I do not wish to Self-Identify. Signature Office Use Only Position applied for Available Not Available Hired Yes No Positions hired for: Other positions considered for: From the EEO job classifications below, which one best describes the position filled? Executive/Senior Level Officials and Managers First/Mid-Level Officials and Managers Professionals Technicians Sales Workers Admin. Support Workers Craft Workers Operatives Laborers & Helpers Service Workers
9 VETERANS PRE-OFFER VOLUNTARY SELF-IDENTIFICATION INVITATION FOR JOB APPLICANTS US GOVERNMENT REQUIREMENT FOR EMPLOYERS WITH FEDERAL VETERANS AFFIRMATIVE ACTION PLANS - 41 CFR (a) This employer is a Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans, defined as follows: A disabled veteran is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. A recently separated veteran means any veteran during the three-year period beginning on the date of such veteran s discharge or release from active duty in the U.S. military, ground, naval, or air service. An active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An Armed forces service medal veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor s Veterans Employment and Training Service (VETS), toll-free, at USA-DOL. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. [ ] I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE [ ] I AM NOT A PROTECTED VETERAN Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. If you receive a job offer, the US government requires us to invite further voluntary identification of your veteran status at that time, as you enter employment, and at any time you wish to disclose said status. PLEASE ENTER YOUR NAME HERE TODAY S DATE A Special Note From _the employer - Affirmative Action under these US laws means facilitating equality of job opportunities and targeted recruiting, not quotas or preferences, which are prohibited. It also means reasonable accommodation to make our application and selection process accessible to persons with disabilities. If you would like to discuss a potential accommodation during this process please let us know. Employer Use Only: Job Group Code: If current opening, Job Applied For: Rev. 9/11/2013