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

Have you previously been employed by Physicians Ambulance? *
Do you know anyone currently employed at Physicians?
Are you legally authorized to work in the United States? *
Have you ever been convicted of a felony? *


Days Available *
Shift preference: *
Employment Status Request *

Employment History

Employer 1
May we contact? *
Employer 2
May we contact? *
Employer 3
May we contact? *


Reference 1
Reference 2
Reference 3

Educational Background

Name of high school
Diploma received? *
School 2
Did you graduate? *
School 3
Did you graduate?

All Applicant Attachments

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


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? *

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.
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? *
Please certify this application with your signature below *