3619 High Street Portsmouth, VA Office: (757) Fax: (757)

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1 3619 High Street Portsmouth, VA Office: (757) Fax: (757)

2 It is the policy of this company to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, physical/mental handicap, or veteran status. APPLICATION FOR EMPLOYMENT POSITION APPLYING FOR: HIRE DATE: PERSONAL INFORMATION First Name Middle Initial Last Name Current Address: Street and Apt. # City State Zip Code Social Security #: - - D.O.B.: Telephone: Cell Phone: I am an U.S. Citizen or otherwise authorized to work in the United States on an unrestricted basis: Yes No If applicable, please list your Visa type, Visa # and expiration:

3 EMERGENCY CONTACT INFORMATION PRIMARY CONTACT Name: Employer: Relationship: Phone: SECONDARY CONTACT Name: Relationship: Employer: Phone: PROFESSIONAL REFERENCES Name: Employer: Relationship: Phone: Name: Relationship: Employer: Phone: Name: Relationship: Employer: Phone: DRIVING RECORD License Number: Expiration Date: State: Infractions ATTACH COPY OF VA STATE DMV RECORD Have you ever been convicted of a felony? Yes No Have you ever been convicted of a misdemeanor? Yes No If you answered yes, please explain: (use the back of this sheet if necessary)

4 CERTIFICATIONS Please Check And Complete All That Apply: EMT-B Certification Number: Expiration Date: EMT-E Certification Number: Expiration Date: EMT-I Certification Number: Expiration Date: EMT-P Certification Number: Expiration Date: E.V.O.C.-Level of Certification: Expiration Date: CPR Association: Expiration Date: B.T.L.S. Association: Expiration Date: P.H.T.L.S. Association: Expiration Date: I.T.L.S. Association: Expiration Date: A.C.L.S. Association: Expiration Date: P.A.L.S. Association: Expiration Date: P.E.P.P. Association: Expiration Date: Critical Care Paramedic TEMS Sanction Letter (for ALS providers) (Please attach a copy of all certifications to the end of this application) EMS Affiliations Present or Most Recent to Prior Department/Company Starting Date: Ending Date: Department/Company Starting Date: Ending Date: Department/Company Starting Date: Ending Date:

5 EMPLOYMENT HISTORY Present or Most Recent Employer Employer: Your Position: Address: Salary: Duties: Dates of Employment: to Supervisor: May we contact? Yes No Name Title Reasons for Leaving: Prior Employer Employer: Your Position: Address: Salary: Duties: Dates of Employment: to Supervisor: May we contact? Yes No Name Title Reasons for Leaving: - Prior Employer Employer: Address: Your Position: Salary: Duties: Dates of Employment: to Supervisor: May we contact? Yes No Name Title Reason for leaving:

6 EDUCATION High School Name and Address Did you graduate? Yes No Attended from to If you did not graduate, did you receive your GED? Yes No Special honors or awards: Technical or Vocational School Name and Address Did you graduate? Yes No Attended from to Degree or Certification: Specialty: Special honors or awards: College or University Name and Address Did you graduate? Yes No Degree: Attended from to Major: Special honors or awards: College or University Name and Address Did you graduate? Yes No Degree: Attended from to Major: Special honors or awards:

7 POSITION INFORMATION Position Specifications Position Applying For: How did you hear about this job? What hours are you willing to work? Would you be able to work weekends, nights, and on call? Yes No When would you would you be able to start? Skills Please describe any skills you have in the following areas: Computer: Languages Spoken (other than English): Other: I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history. Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law. Signature: Date

8 DISCLOSURE AND RELEASE In connection with my application for employment (including contract services) or with EMR, I understand that consumer reports, which may contain public record information, may be requested and obtained. This includes, but not limited to, a criminal history report. In addition, reports, which include information as to my previous driving, including court actions, license suspension and revocations, education and license, and employment including, but not limited to, performance, work habits, character, experience, and reason for termination of past employment from previous employers may be requested. IN ADDITION, BY MY SIGNATURE BELOW I GIVE PERMISSION TO EMR TO OBTAIN ANY OR ALL OF THE ABOVE MENTIONED INFORMATION, I have the right to obtain information as to the name, address and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information as well as the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request. This authorization shall remain on file and shall serve as ongoing authorization for the organization named above to procure consumer reports and police, driving reports, and criminal histories at any time during my employment or contract period. (Signature) (Date) (Print Name) (Social Security Number) (Driver s License Number) * (State) *Please print clearly

9 Substance Abuse Consent Form Applicant s/employee s Name: Company Name: Location: I, understand and agree that I will be tested (Applicant s/employee Signature) for substance abuse or chemical dependency. I understand that I am required to consent to a urine test and /or blood test and submit a sample of my urine and /or blood chemical analysis in accordance with procedures established by qualified laboratory personnel. I understand that if I decline to sign this consent and thereby decline to take the test, the Human Resources Department will be notified and that my employment or employment consideration could be terminated. If the test result is confirmed as positive, the result will be reported to the Human Resources Department. An exception will be made for the use of legally prescribed medication taken under the direction of a physician. A positive, confirmed test may result in the company taking disciplinary action against me up to and including termination for employees, or unfavorable consideration for applicants. I consent freely and voluntarily to this test. I further understand and release, their associate (Company Name) agents and contractors from any and all liability what so ever arising from my urinalysis and / or blood testing procedures and any other conditions as set forth above. Applicant s Employee s Signature Management Signature Date Date

10 Preliminary Questionnaire Position Sought Position Applied For: EMT-B EMT-I EMT-P EVOC Personal Information Full Name: Last First Middle Current Address: Street City State Zip What is your social security number? What is your driver license number? Telephone Number: ( ) Are you at least 18 years old? Yes No Are you authorized to work in the U.S.? Yes No Are you currently employed? Yes No Are you able to lift a minimum of 125 pounds? Yes No How many hours a week do you want to work? Date you can start work: Position desired: Full-time Part-time Shift availability (circle all that apply): Day Evening Night Rotating Day availability (circle all that apply): Mon Tues Wed Thurs Fri Sat Sun Overtime availability: Yes No Are you willing to work on a Holiday if applicable: Yes No Have you ever worked in an emergency medical service related position (or participated in patient care)? Give dates and description of duties Have you applied with us before? Yes No If so, when? Date Position

11 Are you willing to submit to a pre-employment drug test? Yes No Are you aware of any physical limitations that may prevent you from doing this job? Yes No If yes, please explain: Do you have any infractions on your driver s license? Yes No If yes, please explain: What is the point balance on your DMV record: How did you find out about us? Mark one or more of the following: Newspaper Current Employee-Who? Website Past Employee-Who? Other Please specify other: Office Use Date of interview: Performed by: Date of hire: Date employee set up for orientation and training:

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