Online Employment Application

Applicant Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Have you ever worked for Community Ambulance before?*
- Yes
- No
When did you previously work for Community Ambulance and what were the circumstances regarding your departure?
How did you hear about Community Ambulance?*

Employment History
Have you ever been fired or asked to resign?*
- 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:*
Your job responsbilities:*
May we contact Employer #2?*
- Yes
- No
Do you have another employer to add?*
- Yes
- No

Employer #3: Company Name*
Employer #3: Dates employed (From/To)*
Employer #3: Phone*
Employer #3: Supervisor's Name*
Employer #3: Job Title*
Employer #3: Starting Salary*
Employer #3: Ending Salary*
Reason for leaving this employer:*
Your job responsibilities:*
May we contact Employer #3?*
- Yes
- No

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.

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