Employment Application | Echo Hose Ambulance

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Position Applied For?*

If Other, which position*

Days available to work?*

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Hours available to work?

Desired hourly rate of pay?

What type of position are you applying for?

CERTIFICATION

Certification?

If Other, Please list*

Certification number?

Issue Date

Expiration Date

EDUCATION

Have you graduated from High School

Yes

No

If No, what is the highest grade completed?

Did you receive a High School equivalency diploma?

High School

High School Name

High School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of degree received?

Technical or Business

Tech or Business School Name

Tech or Business School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of degree received?

College or University

College or University Name

College or University Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of degree received?

PAST CONVICTION

Have you ever been convicted of a crime?*

If Yes, Please explain*

REFERENCES

Beginning with your PRESENT OR MOST RECENT employment or volunteer experience and working backward, list all positions held which are necessary for determining your eligibility for employment. List all positions (titles) separately; even if with the same employer. Clearly describe the work (duties) you personally performed. You must fill out this application completely even if a resume is being attached.

Reference 1

Official Job Title

Company Name

Type of Business

Title of Immediate Supervisor

Dept. Where Assigned

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start Date

Employment End Date

Salary or Wage

Number of Employees Supervised By You?

Reason for Leaving?

Duties?

Reference 2

Official Job Title

Company Name

Type of Business

Title of Immediate Supervisor

Dept. Where Assigned

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start Date

Employment End Date

Salary or Wage

Number of Employees Supervised By You?

Reason for Leaving?

Duties?

Reference 3

Official Job Title

Company Name

Type of Business

Title of Immediate Supervisor

Dept. Where Assigned

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start Date

Employment End Date

Salary or Wage

Number of Employees Supervised By You?

Reason for Leaving?

Duties?

ACKNOWLEDGEMENT

I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations. All statements made on this application, including employment information, are subject to verification as a condition of employment.

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