Secure Employment Application - Physicians Ambulance

Physicians Ambulance Service, Inc. is an Equal Opportunity Employer. It is our policy to abide by all Federal, State, and Local laws concerning discrimination in employment. No question on this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question herein be used in violation of any such law.

Physicians Ambulance is a Drug Free Workplace: All Applicants will be required to submit to a drug test and agree to the Company Drug Free Workplace Policy.

Personal Information

Today's date * +

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Position Applying For *

Primary Station Preferred *

How did you hear about us?

Have you previously been employed by Physicians Ambulance? *

Yes

No

If yes, please list your previous dates of employment

Do you know anyone currently employed at Physicians?

Yes

No

If yes, please list name and relationship

Are you legally authorized to work in the United States? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain.

Availability

Days Available *

Shift preference: *

Days

Mid-Shift (1pm-5pm)

Night-Shift (5pm-on)

Any

Employment Status Request *

Full-time

Part-time

Modified Part-time

Employment History

Employer 1

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Employer 2

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Employer 3

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

References

Reference 1

Name

Title

Email Address

Phone

Reference 2

Name

Title

Email Address

Phone

Reference 3

Name

Title

Email Address

Phone

Educational Background

Name of high school

Name *

Location *

Years Attended *

Diploma received? *

Yes

No

School 2

Name *

Location *

Years Attended *

Did you graduate? *

Yes

No

Type of degree or certification earned *

School 3

Name

Location

Years Attended

Did you graduate?

Yes

No

Type of degree or certification earned

All Applicant Attachments

Attach a copy of your driver's license *

Attach a copy of one of the following as a 2nd form of ID: social security card, birth certificate, or passport

Field Personnel Attachments

Paramedics: Ohio Paramedic card, BLS CPR card, National Registry card, ACLS, PALS, ITLS

EMTs: Ohio EMT card, BLS CPR card, National Registry card

Wheelchair Van Attendants: AHA Heartsaver CPR/AED card

Attach a copy of your CPR card

Attach a copy of your OH Paramedic or EMT card

Type of Ohio certification

Ohio certification number

Ohio certification expiration date +

Attach a copy of your National Registry card

Attach a copy of your ACLS card (Paramedics)

Attach a copy of your ITLS card (Paramedics)

Attach a copy of your PALS card (Paramedics)

Attach a copy of your CEVO/ EVOC or Defensive Driving Course certificate

List any additional certifications/ training/ courses or comments

Submit a copy of your resume (optional)

Applicant's Certification

Please read carefully before agreeing!

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 misrepresentation or omission of facts in this application may lead to my discharge. I understand that Federal, State, and Local requirements govern the position I am applying for and I will comply with all laws including: fingerprint background check, physical exams and drug screening (both routine and random). I also understand that additional training may be required in order to continue my employment with Physicians Ambulance. If employed, I understand and agree that such employment may be terminated at any time, without prior notice, and that employment will not be governed by and expressed or implied contract, but is at will.

Do you agree with the Applicant's Certification above? *

Yes

No

Today's date * +

Disclosure Under the Fair Credit Reporting Act and Consent to the Procurement of Consumer Report(s) for Employment Purposes

The undersigned herby authorizes Physicians Ambulance or it's insurance agency EZ2Insure, or it's assigns, to obtain copies of consumer reports, including a motor vehicle report, pertaining to me for employment purposes, and for use in rating and/or underwriting insurance for which the above-named employer may apply, and any renewal thereof. I understand that in obtaining such consumer reports, a consumer reporting agency may be used.

I hereby authorize release to Physicians Ambulance information held by parties regarding my previous employment, conviction history, driving history, education or degrees earned, credit history in compliance with all federal and state laws, and hereby release any providers of such information from any liability for providing same. I understand this information may be reviewed initially and periodically by these parties prior to and during employment.

I understand this information is to be utilized as part of the employment process. I also authorize investigation into my worker's compensation claim history if a conditional offer of employment is made to me, in compliance with A.D.A. guidelines; so as to assure I am not being offered a position, which could aggravate a previous injury.

I hereby acknowledge that Physicians Ambulance used third party information and cannot guarantee the accuracy of any such information. I therefore release Physicians Ambulance, its agents, my employer or prospective employer and its agents from any and all liability arising out of any errors or omissions regarding this investigation into my background, and authorize the background investigate agency to proceed with this investigation and release the results.

Please print your name *

Do you agree with the Disclosure Under the Fair Credit Reporting Act and Consent to the Procurement of Consumer Report(s) for Employment Purposes statements above? *

Yes

No

Date of birth * +

Social security number *

Driver's license number *

Driver's license state *

Driver's license expiration date * +

Please certify this application with your signature below *

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