Saving Lives Through Quality Care

“Saving Lives Through Quality Care”

Application for Employment

Note to Applicant: Please advise us in advance if you require an accommodation to complete this application.

EmStar Ambulance is an Equal Employment Opportunity employer. EmStar Ambulance does not discriminate against any applicant or employee on the basis of race, color, sex, religion, national origin, age disability, or any other consideration made unlawful by applicable federal, state and local laws.
As a matter of policy for the safety of the communities we serve, EMStar Ambulance consistently applies background checking standards to all applicants. It is essential that all information requested, including educational background, work, criminal and residential history, be complete and accurate.

Please type or print. Answer all questions, checking all boxes that apply.

Last Name: ______First Name: ______Middle: ______

Street Address: ______City: ______State: ______Zip Code: ______

Primary Telephone Number: ______Secondary Telephone Number: ______Cell Phone Carrier

E-Mail address: ______Social Security #: ______Are you 18 or older? YES or NO

If hired, can you present evidence of your legal right to work in the US? □ Yes□ NoDate of Application: ______

List any other names that you may have used in the past 5 years

Name Used:City:County:State:From/To:

______

List all addresses for the past 5 years

______

Have you ever been fired or asked to resign by an employer? □ Yes□ No

If yes, explain: ______

What position are you applying for? ______Minimum salary/wage requirements: ______

How were you referred to our company? □ Banner □ Flyer □ Print Ad □ On-line Ad □ State Employment Agency □ Job Fair

□ Employee Referral Name: ______□ Other

Have you ever worked for EMStar Ambulance? □ Yes □ NoWhere? ______When? ______

Have you ever applied at EMStar Ambulance? □ Yes □ NoWhere? ______When? ______

If hired, what date are you available to start work? ______

Are you applying for: □ Full-time □ Part-time□ Per-DiemAre you available to work: □ Days □ Evenings □ Weekends

EMStar Ambulance is an Equal Opportunity Employer that values diversity

EDUCATIONAL BACKGROUND

SKILLS

If applicable, please check all your current skills:

□Telephone Rep.□Payroll□Bookkeeping□Customer Service□Dispatch

□Call Center□EMT-B□EMT-P□Other

Explain other skills: ______

______

DRIVER LICENSE INFORMATION

State / License # / Type / Expiration Date

CERTIFICATION INFORMATION

EMT/MEDIC / Certification # / Date issues / Expiration Date / Years of experience

EMPLOYMENT HISTORYAll employment for the past 5 years must be noted below, including jobs while in school or while in the military. Record your present or most recent position first and go back in chronological order. Complete all questions for each position.

PROFESSIONAL REFERENCES

Please list 3 professional references who can verify your work history and performance. References should not be relatives and at least 2 must have directly supervised you at some point in your work history.

Please print:

Name of Supervisor:______Title:______

Company Name & Address: ______

Company Telephone # (including extension):______

Name of Supervisor:______Title:______

Company Name & Address: ______

Company Telephone # (including extension):______

Name of Supervisor:______Title:______

Company Name & Address: ______

Company Telephone # (including extension):______

CRIMINAL CONVICTION HISTORY

EMStar Ambulance strives to provide a safe environment for our employees, the communities we support, and the patrons we transport. For these reasons, all applicants must provide a complete adult criminal conviction record subject to federal and state mandated restrictions. This includes any conviction and/or criminal charge where the final disposition is still pending. Please note that a criminal conviction history will not necessarily disqualify an applicant from employment. Factors as age, seriousness and nature of the violation as it relates to the applicable position shall be considered.

ACCIDENT REVIEW FOR THE PAST 3 YEARS

TRAFFIC CITATIONS/ CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS (other than parking violations)

Location / Date / Charge / Penalty

VOLUNTARY DISCLOSURE FORM

Date: ______

Regulations of the Equal Employment Opportunity Commission (EEOC) and the Office of Federal Contract Compliance Programs (OFCCP) require employers to compile data regarding the nature and makeup of their work forces in order to further goals of Title VII of the Civil Rights Act of 1964 as amended. Your responses to the following questions will help us comply with this requirement.

Completion of this questionnaire is entirely voluntary. Should you opt to complete the questionnaire, your response will be used solely for the purpose of preparing reports required by the EEOC. Your response will be kept confidential, and will play no part in our evaluation of your suitability for employment, employment performance or status. The completed questionnaire will be kept separate from your application, and any subsequent personnel file.

We appreciate your assistance.

Position applied for (indicate only one position per form): ______

Last 4 digits of Social Security Number: XXX-XX-______Gender (check one): □ Male (M)□ Female (F)

Group Status (check one):

□Hispanic or Latino (Cuban, Mexican. Puerto Rican, South or Central American or Spanish culture or origin regardless of race)

□White (Not Hispanic or Latino)

□Black or African America (Not Hispanic or Latino)

□Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

□Asian (Not Hispanic or Latino)

□American Indian or Alaska Native (Not Hispanic or Latino)

□Two or More Races (Not Hispanic or Latino)

Referral Source (check one):

□ Banner □ Flyer □ Print Ad □ State Employment Agency

□ Employee Referral □ Other□ On-line Ad □ Job Fair

EMStar Ambulance is an Equal Opportunity Employer that values diversity