Jeannette E.M.S., Inc.
Application for Employment
Please print this
application and mail it to:
Operations Manager
Jeannette E.M.S., Inc.
225 S. 6th Street
Jeannette,
PA 15644-3417
Date of Application________________________________.
Position applying for (
)EMT ( )Paramedic ( )Health Care Professional ( )other____________
Full Name
_____________________________________________________________________
Last Name First Name
M.I.
Address_______________________________________________________________________
Number Street City State Zip
IF you did not live at this address for at least 5 years,
please provide previous address
Address_______________________________________________________________________
Number Street
City
State Zip
Telephone Number ( )____________________________
Are you at least 18 years or older? (
)Yes ( )No
Do you understand that the job that you are applying for
will consist of lifting people on stretcher’s ( )Yes ( )No
Are you applying for (
)Full Time ( )Part Time ( )Per-diem (fill-in)
Are you able to fully perform the job that you are
applying for? ( )Yes (
)No
What shifts are you available for?
__________________________________________________
Can you work weekends? ( )Yes ( )No
Have you ever been convicted of a felony? ( )Yes
( )No If yes, please explain
_____________________________________________________________________________.
_____________________________________________________________________________.
Drivers License #__________________________ State
Issued___________________________
Expiration Date____________________________ Do you have
EVOC? ( )Yes ( )No
Jeannette E.M.S., Inc.
Employment Application
Page 2
In the last 7 years have you had any driving violations?
( )Yes ( )No, If yes, please
explain
_____________________________________________________________________________.
_____________________________________________________________________________.
If you are hired you will be required to take a physical
examination, do you agree to this?
( )Yes (
)No
If you are hired you will be required to take a drug
test, do you agree to this?
( )Yes (
)No
PA Department of Health ID number__ __
__ __ __ __ Expiration date
____/____/____
CPR Expiration Date____/____/____ All aspects? ( )Yes ( )No
Do you have ACLS? (
)Yes ( )No expiration date ____/____/____
Please list below any other training that you have that
would help consider your application for employment.
____________________________________________________________________________.
____________________________________________________________________________.
Please note, this application must have attached to it copies of all certifications that you hold necessary to be considered for employment. Including you drivers license and EVOC certification.
List all previous employers
from the most recent to the last.
Employer_________________________________________Type of
business_______________
_______________________________________________________( )__________________.
Address
City
State Zip Telephone
Dates of employment ____/____/____ to ____/____/____
Position held?___________________
Name of Supervisor_________________________ May we contact
( )Yes ( )No
Was employed (
)Full time ( )Part Time Reason
for Leaving?__________________________
Duties preformed?_______________________________________________________________
******************************************************************************
Jeannette E.M.S., Inc.
Employment Application
Page 3
Employer_________________________________________Type of
business_______________
_____________________________________________________( )__________________
Address
City
State Zip Telephone
Dates of employment ____/____/____ to ____/____/____
Position held?___________________
Name of Supervisor_________________________ May we contact
( )Yes ( )No
Was employed (
)Full time ( )Part Time Reason
for Leaving?__________________________
Duties
preformed?_______________________________________________________________
Employer_________________________________________Type of
business_______________
_______________________________________________________( )__________________.
Address
City
State Zip Telephone
Dates of employment ____/____/____ to ____/____/____
Position held?___________________
Name of Supervisor_________________________ May we contact
( )Yes ( )No
Was employed (
)Full time ( )Part Time Reason
for Leaving?__________________________
Duties
preformed?_______________________________________________________________
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Jeannette E.M.S., Inc.
Employment Application
Page 4
I certify that to the
best of my knowledge and belief the answers given by me to the foregoing
questions and the statements made by me in this application are correct and
complete. I understand that any false
information contained in this application will result in my discharge.
I
authorize you to communicate with all of my former employers, school officials
and persons named as references. I
hereby release all employers, schools and individuals from any liability for
any damage what so ever resulting from giving such information. I authorized Jeannette E.M.S. to photocopy
my signature below along with this statement and send this to any holder of
information.
I
understand that as this organization deems necessary, I may be required to work
overtime hours or hours outside a normally defined workday or workweek. If employed, I understand and agree that
such employment may be terminated at any time and without any liability to me
for any continuation of salary, wages, or employment related benefits.
I
understand that all equipment issued to me by the Jeannette E.M.S., Inc. is the
property of the Jeannette E.M.S. and will be turned in to a designated
representative of the organization upon request. I do understand if any equipment issued to me by the Jeannette
E.M.S., Inc. is lost, stolen or damaged I am responsible for said equipment.
I
understand if employed by the Jeannette E.M.S., Inc. I will receive an employee
handbook that I will read and submit to the Operations Manager signed
documentation stating that I have received the handbook.
_______________________________________ _________________________.
Signature of Applicant Date
OFFICE
USE ONLY
DATE INTERVIEWED_____________________________
INTERVIEWED BY___________________________
INTERVIEWING COMMITTEE
COMMENTS__________________________________________________________________________________
DATE HIRED__________________STARTING SALARY____________
STARTING DATE_________________
DATE DISMISSED_________________________
REASON_____________________________________________________________________________________
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