Employment Application – Osage Ambulance District

Step 1 of 11

Personal Information

Legal Name:*

First Middle Last

Current Address:*

Street Address Address Line 2 City State ZIP Code

Have you been at your current address for less than 3 years?

Yes

Previous Address:*

(since you have been at your current address less than 3 years)

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:*

Email Address:*

License Information

Do you have a current Missouri State EMS License?*

Yes

License Number:*

Are you Nationally Registered?*

Yes

National Registry Number:*

Do you have a valid driver's license?*

Yes

License State:*

License Number:*

License Class:*

Education Information

Must be 18 years old and have a high school diploma or GED.

Secondary School

School Name:

City / State:

Years Attended:

Date Graduated:

MM slash DD slash YYYY

Field(s) of Study:

College/University

School Name:

City / State:

Years Attended:

Date Graduated:

MM slash DD slash YYYY

Field(s) of Study:

EMT Training

School Name:

City / State:

Years Attended:

Date Completed:

MM slash DD slash YYYY

Paramedic Training

School Name:

City / State:

Years Attended:

Date Completed:

MM slash DD slash YYYY

Qualifications

CPR

Month and Year of Expiration:

Location of Course:

PHTLS

Month and Year of Expiration:

Location of Course:

PALS

Month and Year of Expiration:

Location of Course:

ACLS

Month and Year of Expiration:

Location of Course:

Additional Training

List additional training programs that you have completed:

Employment History

List present or most recent positions first.

Present / Most Recent Employer

Name of Employer:*

Address:*

Street Address Address Line 2 City State ZIP Code

Start Date:*

MM slash DD slash YYYY

Are you presently working here?*

Yes

End Date:*

MM slash DD slash YYYY

Position:*

Starting Salary:

Current/Ending Salary:*

May We Contact Your Supervisor?*

Yes

Name of Supervisor:*

Supervisor's Title:*

Supervisor's Phone Number:*

Describe Your Duties:

Reason For Leaving:*

Previous Employer

Name of Employer:

Address:

Street Address Address Line 2 City State ZIP Code

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Position:

Starting Salary:

Ending Salary:

May We Contact Your Supervisor?

Yes

Name of Supervisor:

Supervisor's Title:

Supervisor's Phone Number:

Describe Your Duties:

Reason For Leaving:

Previous Employer

Name of Employer:

Address:

Street Address Address Line 2 City State ZIP Code

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Position:

Starting Salary:

Ending Salary:

May We Contact Your Supervisor?

Yes

Name of Supervisor:

Supervisor's Title:

Supervisor's Phone Number:

Describe Your Duties:

Reason For Leaving:

References

(Please do not list relatives or former employers)

Reference #1

Name:*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Years Acquainted:*

Reference #2

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Years Acquainted:*

Reference #3

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Years Acquainted:*

Reference #4

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Years Acquainted:*

Legal Issues

Have you ever driven an emergency vehicle?*

Yes

If yes, what type and for how long?*

Has your license ever been suspended or revoked?*

Yes

When and for what?*

List most recent traffic offenses citation, including: date, place and disposition:

Leave blank if none.

List next more recent traffic offense citation, including: date, place and disposition:

Leave blank if none.

List any accidents you have been involved in the last 5 years:

Leave blank if none.

Explain any additional citation or accident information:

Leave blank if none.

Driving Experience

Have you ever been convicted of, including: date, place and disposition?*

Yes

List any criminal offenses that you have been convicted of, including: date, place and disposition:*

Have you ever had a judgment against you in a medical malpractice suit?*

Yes

Please explain:*

Has your medical malpractice insurer ever paid on a claim involving your alleged medical malpractice?*

Yes

Please explain:*

EMS Skills Summary

Indicate which of the following skills you have performed in the last year:

Airway: Oral/Nasal

Fracture Management

Stair Chair

Airway: Combi-Tube/King

Glucose Determination

Stretcher: Ambulance

Airway: Endotracheal

IV Establishment

Stretcher: Stair Chair

Ambulance Driving

IV: Blood Draw

Suction: Oral

Childbirth

MAST Trousers

Suction: ET/Nasal

Choking Management

Medication Admin: IM

Triage

Decontamination

Medication Admin: IV

Traction Splint

Defibrillation: Automatic

Medication Admin: Oral

Ventilator

Defibrillation: Manual

Medication Admin: SL

Dispatching

Oxygen Administration

EKG Interpretation

Spinal Immobilization: Short

External Pacing

Spinal Immobilization: Long

Extrication

Splinting

Please list any additional skills performed in the last year that are not listed:

Affirmation and Additional Remarks

Do you agree to take a medical exam including drug and/or alcohol screening at company expense, evaluating the Bone Fide Occupational Qualifications of the position?

Yes

We appreciate your interest in seeking employment with us – please feel free to make any additional remarks in the space provided below or attach any additional information that would be helpful in evaluating your qualifications.

Authorization

I hereby certify that to the best of my knowledge and belief the answers given by me to the foregoing questions and all statements made by me in the application are correct.

If employed, I agree that all material created and produced whether in written, graphic or broadcasting form, all inventions new or changes in processes developed during my employment are the exclusive property of the company to use and/or sell and that subsequent to my employment with this company I will not disclose, use or reveal and confidential information related to the company without first obtaining written consent from an officer with this company.

I hereby apply for employment upon the basis and understanding that such employment may be terminated at any time upon notice given to me personally or sent to my last known address.

I consent that you the employer, or its agents, may obtain both personal and job related information that is relevant to the consideration of this application for employment.

Signature

Date Signed:

MM slash DD slash YYYY

EMS Employment Application

Personal Information

License Information

Education Information

Qualifications

Employment History

References

Legal Issues

Driving Experience

EMS Skills Summary

Affirmation and Additional Remarks

Authorization