MedEx Medical Transport Services, Inc. 902 East Memorial Drive PO Box 506 Ahoskie, NC 27910 (252) 332-4555 03-01-2011 Dear Applicant, MedEx would like to thank you in advance for considering employment with our company. Please complete the application and bring in the following items when you return your application. Incomplete applications will not be considered for employment. 1. Fill out the application completely. Please sign the application in the 3 designated areas. Leaving questions blank may eliminate you for consideration of employment. 2. Document your complete employment history. You may use the back of the page, if necessary. 3. Applicants shall attach a copy of the following documents: a) Driver s License & Social Security Card b) OEMS Credential Card c) Shot Record TB Skin Test/Screening and Hepatitis B Vaccine d) Local Criminal Background Check e) Copy of Driving Record This application for consideration of employment shall be active for a period of time, not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should resubmit an application. If you have any questions, please contact MedEx, Inc. at the above telephone number. 1
APPLICATION FOR CONSIDERATION OF EMPLOYMENT 03-01-2011 ============================================================================== We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. Position(s) Applied For Date of Application Last Name First Name Middle Name Address City State Zip Code _(H) (C) Number Date of Birth Social Security Number (Optional) Are you currently employed? Yes No If so, may we contact your present employer? Yes No On what date would you be available to begin work? Full Time Part Time Do you have a criminal background other than traffic violations? Yes No If yes, explain: List fields of certifications and/or licenses Personal References: Job related or professional preferred. (References must not be related to you) 1. Name Phone # Complete Mailing Address 2. Name Phone # Complete Mailing Address 3. Name Phone # Complete Mailing Address EDUCATION Name and Address of School Course of Study Years Completed Diploma/Degree High School College Other (Specify) 2
EMPLOYMENT EXPERIENCE Start with your present or last job. Include any job-related military service assignment and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status. 3
MedEx Medical Transport Services, Inc. APPLICANT S STATEMENT I hereby authorize MedEx to conduct an investigation into my background, which may consist of the following: employment history, education, criminal background records, and other records that may be appropriate and necessary in making an employment decision. This application for consideration of employment shall be active for a period of time, not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should resubmit an application. I understand that the offer of employment to work for MedEx, Inc. is conditioned on a signed consent to a State and/or National Criminal History Record Check of the applicant. MedEx, Inc. will not employ an applicant who refuses to consent to the required criminal history record check. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. I hereby attest to the facts, set forth in my application for employment, are true and complete to the best of my knowledge. In the event of employment, I understand that any false statement, omission of information or misleading information on my application form or interview(s) may result in immediate termination of employment. I understand that I am required to abide by all rules and regulations of MedEx, Inc. Signature of Applicant Date 4
AUTHORIZATION / WAIVER FOR INVESTIGATION OF APPLICATION I hereby fully waive any rights or claims that I have or may have against all current and/or former employers and their agents, employees and representatives and damages that may directly or indirectly result from the use, disclosure or release of any information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claim against you and/or any outside agency utilized by you as a result of any information which is obtained in this investigation. Applicant s Signature Do not write below this line =============================================================================== Applicant s Name: SS# Place Worked: Phone #: s Name: Person Giving Reference / Title: Dates of Employment: Start Ending Job Title: Eligible for Rehire: Yes No Attendance Record: excellent good fair poor Additional Comments: Person Completing Reference Sheet Date 5
AUTHORIZATION / WAIVER FOR INVESTIGATION OF APPLICATION I hereby fully waive any rights or claims that I have or may have against all current and/or former employers and their agents, employees and representatives and damages that may directly or indirectly result from the use, disclosure or release of any information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claim against you and/or any outside agency utilized by you as a result of any information which is obtained in this investigation. Applicant s Signature Do not write below this line =============================================================================== Applicant s Name: SS# Place Worked: Phone #: s Name: Person Giving Reference / Title: Dates of Employment: Start Ending Job Title: Eligible for Rehire: Yes No Attendance Record: excellent good fair poor Additional Comments: Person Completing Reference Sheet Date 6