Company Empress Ambulance Emergacare

Position Applied for Emergency Medical Technician Paramedic Dispatcher Customer Service Representative Mechanic  Email Address

Are You At Least 18 Years of Age Yes No   

Last Name: First Name: Middle Initial

Street Address Apt. # City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code   Phone Number Other Phone

Are you currently employed?                          Yes No

Date you Can Begin to Work                          Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

I am available to work (check all that apply)  

Full Time Per-Diem         Days Nights Weekends

Have you ever filed an application with us?       Yes No      If yes give date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec n/a 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 n/a

Have you ever been employed with us before?   Yes No      If yes give date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec n/a 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 n/a

Have you ever been convicted of a felony?         Yes No     

Charge(s)  

Are you a U.S. citizen or alien lawfully permitted to work in the U.S.     Yes No

How many years have you been driving? None 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 More Than 30

What state is your drivers license? AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  

Professional Certifications (please describe i.e. CPR etc.)

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List any other additional training, apprenticeships, activities or officers held, language,
computer or specialized skills, or any other information you feel would be helpful to us
in considering your application.

In completing this application for employment, and any supplements to this application, I certify that information given herein is true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts is cause for cancellation of this application or separation from the company’s service if I am employed I understand also, that I am required to abide by all rules and regulations of the employer. I agree that Empress shall not be liable in any respect if my employment is terminated because of the falsity of statements made by me on this application.

I authorize investigation of all statements contained in this application as may be necessary for arriving at an employment decision. I understand that information concerning my past record will be sought from my previous employers and other sources and I hereby release from all liability or damages those individuals, corporations, or organizations who provide such information. I understand that any such information provided shall become the exclusive property of the company.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the company is of an ‘at will’ nature, which means that I may resign at any time and Empress may discharge me at any time with or without cause. I further understand that this ‘at will’ relationship may not be changed unless specifically agreed to in writing by an authorized executive of this company.

This certifies that this application was completed accurately and honestly by me or at my direction.