General Information

Position applying for:

Are you a Certified EMT? Yes No

Basic - Certificate Expires
Intermediate - Certificate Expires

Are you a Certified Paramedic? Yes No Certificate Expires

Are you nationally registered? Yes No Certificate Expires

Available to work: Full-time Part-time Temporary

Date available to start work:

If you are under age 18, can you provide a work permit if offered a job? Yes No

If you are not a U.S. Citizen, do you have the right to work in the U.S.? Yes No

Have you been convicted of a felony within the last 10 years? Yes No

(A conviction is not an automatic bar to employment. Each case will be considered on its own merits.)

If yes, please explain:

Have you been convicted of a crime relating to the use, sale, possesion or transportation of narcotics, habit forming or dangerous drugs? Yes No

If yes, please explain:

Do you currently use illegal drugs? Yes No

If yes, please explain:

Have you been convicted of theft within the last ten years? Yes No

If yes, please explain:

Have you ever applied for a position with or worked for this company before? Yes No

If yes, specify dates:

EDUCATION

College

Name and Address of School

Major

# of Years Completed Did You Graduate? Yes No

High School

Name and Address of School

# of Years Completed Did You Graduate? Yes No

Other (specify)

Name and Address of School

Major

# of Years Completed Did You Graduate? Yes No

EMPLOYMENT

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Present Employer

Please identify and explain all periods of unemployment in excess of one month during the past five years.

Period of & Reason for Unemployment

To assist us to check records and to verify prior employment and education, please indicate whether you were ever employed or enrolled under a name other than that used on this application:

Please specify the name you were employed or enrolled under:

If you are employed now, may we contact your current employer? Yes No

Are you a veteran of the United States military service? Yes No

If yes, please state branch of service:

Please list any job-related professional, trade business or civic activities, organizations and associations:

(You may omit those which indicate race, color, religion, national origin, ancestry, sex or age.)

Below, list any and all traffic citations received and accidents you have been involved in during the last five years:

Driver's License Number State

Has your drivers' license ever been suspended or revoked? Yes No

If yes, please explain

References

Please provide the names, addresses, and telephone numbers of at least two references who are not related to you:

Person to be contacted in the event of an accident or emergency:

I certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by the Company unless I have indicated to the contrary. I authorize the references listed, as well as all other individuals whom the Company contacts, to provide the Company any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Company as well as from the use or disclosure of such information by the Company or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my dismissal from employment.

I understand that this application is not a contract of employment.

In consideration of my employment, I agree to conform to the rules and standards of the Company, as amended by the Company from time to time in its discretion. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the Company. I understand that no employee or representative of the Company, other than its president, has the authority to enter into any agreement for any specified period of time, or to make any agreement contrary to the foregoing. Further, the president of the Company may not alter the "at-will" nature of the employment relationship unless he does so specifically and in a writing that he signs.

I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States.

Check this box to indicate that you understand and agree to the terms stated above.

Date