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Applicant Personal Information
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Address
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Have you ever worked for Community Ambulance before?
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When did you previously work for Community Ambulance and what were the circumstances regarding your departure?
How did you hear about Community Ambulance?
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Applying for which position?
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Salary Desired
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Please be specific.
Days of the Week Available:
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All days of the week
Monday
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How many hours can you work weekly?
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Will you work overime if asked?
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Yes
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Can you work nights?
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Employment Desired
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Full-time only
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If you are under the age of 18, can you provide proof of eligibility to work?
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Are you authorized to work in the United States?
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Have you ever been convicted of a felony?
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Please provide details regarding your felony conviction:
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Do you have a driver's license?
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License number
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Please list any accidents or moving violations within the past three years:
Has your drivers license ever been suspended, revoked, denied, or cancelled?
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Education & Military History
Please check all of the education levels that you have completed:
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GED
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Post Graduate/Other
Please list name of college, year graduated, and degree conferred
Have you ever been in the Armed Forces?
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No
Please list your military service history including specialty, date entered, and discharge date as appropriate.
Are you now a member of the National Guard?
Yes
No
Employment History
Have you ever been fired or asked to resign?
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Yes
No
Employer #1: Company Name
*
Most recent or current
Employer #1: Dates employed (From/To)
*
Employer #1: Phone
*
Employer #1: Supervisor's Name
*
Employer #1: Job Title
*
Employer #1: Starting Salary
*
Employer #1: Ending Salary
*
Reason for leaving (or wanting to leave) this employer:
*
Your job responsibilities:
*
May we contact Employer #1?
*
Yes
No
Did you have an employer before this one?
*
Yes
No
Employer #2: Company Name
*
Employer #2: Dates employed (From/To)
*
Employer #2: Phone
*
Employer #2: Supervisor's Name
*
Employer #2: Job Title
*
Employer #2: Starting Salary
*
Employer #2: Ending Salary
*
Reason for leaving this employer:
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Your job responsbilities:
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May we contact Employer #2?
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Yes
No
Do you have another employer to add?
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Yes
No
Employer #3: Company Name
*
Employer #3: Dates employed (From/To)
*
Employer #3: Phone
*
Employer #3: Supervisor's Name
*
Employer #3: Job Title
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Employer #3: Starting Salary
*
Employer #3: Ending Salary
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Reason for leaving this employer:
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Your job responsibilities:
*
May we contact Employer #3?
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Yes
No
Are you applying for an EMT-I, Paramedic, or RN position?
*
Yes
No
What professional training and certification do you have?
EMT-B
EMT-I
Paramedic
BCLS/CPR
ACLS
RN
CCT
Other
None
Please prodivde details of the 'other' training/certifications you have:
Please list the name and location of training, certification numbers and expiration dates:
For the certification timeframes below, please round your answer down to the nearest year. For example, if you have 3.5 years experience as an RN, just list 3.
Years of experience as an EMT-B
Years of experience as an EMT-I
Years of experience as a Paramedic
Years of experience as a CCT Paramedic
Years of experience as a Nurse
Please summarize any additional EMS skills, training, or certifications applicable to the specific position for which you are applying.
Please list three professional references (managers, preceptors, coworkers, etc.), phone numbers, and indicate if we may contact them:
By clicking submit below you agree to the following terms:
I certify that my answers are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This includes the requesting of an investigative consumer report as well as a check of my criminal history. I hereby fully waive any rights, or claims 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 party, whether such information is favorable or unfavorable to me. I further waive any claim against Community Ambulance and any outside agency utilized by Community Ambulance as a result of any information obtained in this investigation. If this application leads to employment, I understand that false, missing, or misleading information on this application or interview may result in discharge. This application is submitted with the understanding that upon acceptance of a formal employment offer, I will be required to successfully pass Community Ambulance's pre-placement testing, which will include a written and practical test, drug screening, and MVR check. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand all applicants will be subject to drug testing. I 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 that an Employer may discharge Employee at any time with or without cause. It is further understood the employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. Community Ambulance is an Equal Opportunity Employer.
CAAS Accredited
We are proud to be accredited by the Commission on Accreditation of Ambulance Services
American Ambulance Association
We are proud to be active members of the American Ambulance Association.
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Community Ambulance
91 Corporate Park Drive, Suite 120
Henderson
,
NV
89074
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Info@CommunityAmbulance.com
(702) 222-9111
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