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ONLINE EMPLOYMENT
Online Employment Application
JeffMasterAdmin
2018-08-06T13:00:51+07:00
Employment Application(2)
Step
1
of
8
12%
Applicant Personal Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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?
*
Applying for which position?
*
Salary Desired
*
Please be specific.
Days of the Week Available:
*
All days of the week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many hours can you work weekly?
*
Will you work overime if asked?
*
Yes
No
Can you work nights?
*
Yes
No
Employment Desired
*
Full-time only
Part-time only
Full or Part-time
If you are under the age of 18, can you provide proof of eligibility to work?
Yes
No
Are you authorized to work in the United States?
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Please provide details regarding your felony conviction:
*
Do you have a driver's license?
*
Yes
No
License number
*
State of Issue:
*
Please list any accidents or moving violations within the past three years:
Has your drivers license ever been suspended, revoked, denied, or cancelled?
*
Yes
No
Education & Military History
Please check all of the education levels that you have completed:
Did not graduate HS
GED
High School Diploma
Some College
College (2 or 4 year degree)
Post Graduate/Other
Please list name of college, year graduated, and degree conferred
Have you ever been in the Armed Forces?
Yes
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?
*
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
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.
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