PAST EMPLOYMENT

Have you ever been:

Disciplined or terminated for reckless driving?                                Yes        No

Placed on probation or terminated for excessive absenteeism?      Yes        No

Disciplined or fired for insubordination?                                           Yes        No

Disciplined or fired for violation of safety rules?                              Yes        No

Disciplined or fired for assault or fighting?                                       Yes        No

Disciplined or fired for harassment?                                                  Yes        No

Disciplined or fired for patient abuse?                                               Yes        No

Disciplined or fired for alcohol or drug related activity at work?     Yes        No

If you answered yes to any question above, please explain:

 

EDUCATION AND TRAINING

HIGH SCHOOL:

Name:          Address:

Years completed:                               Did you graduate?  Yes     No

If not, highest grade completed:       Have you received your GED?   Yes    No

COLLEGE:

Name:          Address:

Years completed:                               Did you graduate?  Yes     No

If not, highest grade completed:

Degree:       Major:

OTHER COLLEGE:

Name:         Address:

Years completed:                              Did you graduate?  Yes     No

If not, highest grade completed:

Degree:       Major:

TECHNICAL SCHOOL:

Name:        Address:

Years completed:                             Did you graduate?  Yes     No

If not, highest year completed:

Certificate:       Expires:

License:            Expires:

OTHER SCHOOL/TRAINING:

Name:              Address:

Years completed:                                   Did you graduate?  Yes     No

If not, highest year completed:

Certificate:          Expires:

License:               Expires:

Other:

EMS/FIRE SERVICE RELATED TRAINING NOT LISTED ABOVE:

EMS/FIRE/PROFESSIONAL AFFILIATIONS (other than listed under prior employment):

Describe any additional qualifications or information, personal or professional, that you feel would be

beneficial for us to know when considering your application:

 

REFERENCES

List three persons, other than relatives, who have knowledge of your work experience and/or education.

I.

Name:                   Address:

Occupation:         Years Known:

Telephone Number (including area code):

 

II.

Name:                 Address:

Occupation:        Years Known:

Telephone Number (including area code):

 

III.

Name:               Address:

Occupation:      Years Known:

Telephone Number (including area code):

 

List two personal references that have known you for at least three years outside work.

I.

Name:                 Address:

How they know you:     Phone Number (including area code):

II.

Name:                 Address:

How they know you:     Phone Number (including area code):

 

ACKNOWLEDGMENT:

I certify that the information I have given on this application is true, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the Company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment. If offered a position and at any time thereafter, I consent to medical examination as may be required to determine my fitness to perform the job duties. I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by the Company as a condition of my employment, and I hereby give my consent to the release of all information which the Company deems necessary to determine my ability to perform job duties now or in the future. I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from this Company. I hereby authorize the Company to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release the Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded, my employment with the Company may be terminated.

By selecting yes you agree to the above acknowledgment. Select no to decline.

Yes    No