Application for Employment Form | Shawano Ambulance Service | 911 Service | Critical Care | Emergency Medical Treatment | EMS

Applicant Information

Full Name:

Driver's License Number and State:

Previous Last Name Used:

Current Street Address:

City:

State:

Zip:

Area Code and Phone Number:

Email:

If not a resident at current address for 2 years, give previous address:

Previous Street Address:

Previous City:

Previous Zip:

Do you have the legal right to work in the United States?

Date of Birth

Can you provide proof of age?

List states and counties of residence for the past 7 years:

Have you ever been convicted of a felony?

NOTE: Do not answer "yes" if your "official" conviction record has been annulled, expunged or sealed. A past criminal history does not necessarily disqualify an applicant from exployment.

Do you have any relatives or friends working for this Company?

If yes, which department?

In case of an Emergency who should we notify? (give name, address and phone number)

Job Interest

Position Applying For:

Referred By:

Are you willing to work overtime?

Yes No

Are you willing to work weekends?

Yes No

Date available to begin work

Are you 18 or over? (if no, you may need to provide a work permit)

Yes No

Are you 21 or over?

Yes No

Current Employment

Are you employed now?

Yes No

If not, how long since last employment?

If, yes where?

Date From:

Date To:

Postiion You Held

If not employed, what was reason for leaving?

Education

High School

From Mo/Yr?

To Mo/Yr?

Did you graduate?

Yes No Attending

List Diploma or Degree

College or University

From Mo/Yr?

To Mo/Yr?

Did you graduate from College/University?

Yes No Attending

List Degree or Certificate

List other education:

References

Please list two persons who know of your qualifications and work abilities (do not include relatives).

Reference Name 1:

Address:

Phone:

Occupation:

Reference Name 2:

Address:

Phone:

Occupation:

Employment History

List below your Employment History, beginning with your most recent employer. Account for all periods of time, including part-time work, military service or unemployment. May we contact your present employer for references? If additional space is needed, please put in the additional comments section at the end of this application.

Employer 1:

Employer Name:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Employed From:

Employed To:

Position Held:

Salary / Wage:

Reason for Leaving Employment:

May we contact this employer?

Yes No

Were you fired?

Yes No

Employer 2:

Employer Name:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Employed From:

Employed To:

Position Held:

Salary / Wage:

Reason for Leaving Employment:

May we contact this employer?

Yes No

Were you fired?

Yes No

Employer 3:

Employer Name:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Employed From:

Employed To:

Position Held:

Salary / Wage:

Reason for Leaving Employment:

May we contact this employer?

Yes No

Were you fired?

Yes No

Add any other comments if needed:

Release and Consent

I understand and certify that all information supplied in this application, and any resume, is complete and correct. Any false, misleading or incomplete information furnished by me regarding this application may result in the rejection of this application or if employed, dismissal. I agree to conform to the rules and regulations of the Employer, and further agree that my employment and compensation are at the will of the Employer and can be terminated, with or without cause, and with or without notice, at any time at the option of either the Employer or myself. I understand and agree that these terms can only be modified in writing. No supervisor, representative, agent or other employee of the Employer has now or has had in the past the authority to enter into any agreement for employment for a specified period of time, or to make any agreement which is contrary to or in modification of the above terms, nor can any policies or practices of the Employer, either written or oral, modify the above terms.

I understand and agree to take any physical examination, including drug screening test; all such tests will be administered in compliance with the Americans With Disabilities Act.

I understand and hereby authorize all person, schools, companies, employers and/or their representatives to furnish verification to the Employer, its representatives or agents, any and all information set forth in this application and/or resume. In addition, I hereby agree to hold harmless and to release from all liability all said persons, schools, companies, employers and/or their representatives from any and all claims that I may have, or which may arise, against and and/or all of them, including the Employer, as a result of them furnishing information to the Employer. I authorize the Employer, should they employ me, to release employment references, if my employment becomes terminated for any reason. I also authorize the Employer to conduct credit, police, criminal and driving record inquiries, or any other employment related inquiries in compliance with the provisions of the Fair Credit Reporting Act, 15 U.S.C. Section 1681, et. Seq. I understand that the decision to hire me and my continued employment will be subject to the results of these inquiries.

I understand this application will be active for employment consideration for 30 days. After 30 days, if I wish to be considered for employment, I must contact the Employer to determine if applications are being accepted.

Authorization to obtain Consumer Reports

Consumer reports may be necessary to evaluate my application for employment, or my job status if employed. These reports may include my driving record or other reports.

By signing this agreement, I authorize the procurement of such reports now and as needed in the future, to evaluate my status for employment, insurability, and for any other permissible purpose.

Select a Date:

Applicant/Employee Name (approval of above):

Applicant/Employee Driver License Number: