Position Applied For
EMT-Basic EMT-Paramedic
How did you learn about us?
Advertisement Employment Agency Friend Relative Inquiry Other
If Other please explain:
Your Name:
Your Address:
AL AK AR AZ 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
Telephone Number:
What is the best time to contact you?:
Any Time 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM
If you are under 18 years of age, can you provide required proof of eligibility to work?
Yes No
Are you currently employed?
Yes No
May we contact your present employer?
Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.
Yes No
Date available for work:
—Please choose an option— January February March April May June July August September October November December —Please choose an option— 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - or - Available Immediately
What is your desired salary range?
Are you available to work?
Full Time Part Time Temporary
If available for full time select shift desired:
Any A Shift B Shift C Shift
Are you currently on "lay-off" status and subject to recall?
Yes No
Can you travel if a job requires it?
Yes No