Job Application

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Name

Present Street Address

City

State

Zip Code

How long have you been at your present address?

Telephone Number (Include Area Code)

Driver’s License Number

Driver’s License State

Do you have a National Registry certification?(required)

Yes No

Please enter your National Registry Certification number (if applicable).

Do you have an Alabama state EMS license/certification?(required)

Yes No

Please enter your Alabama state license number (if applicable).

Do you have an American Heart Association BLS Provider CPR certification?(required)

Yes No

May we send the results of your application to the above email address?(required)

Yes No

Are you 18 years of age or older?(required)

Yes No

Have you ever been convicted of any type of traffic violation?(required)

Yes No

If you answered yes to the above question, please include an explanation here.

Have you ever been convicted of a misdemeanor or felony crime?(required)

Yes No

If you answered yes to the above question, please include an explanation here.

Please select the position(s) you are applying for.(required)

Salary Desired

Employment Class Desired(required)

Part-Time Full-Time Full- or Part-Time

When are you available to start?

Education: Please list the name of the high school you attended.

Years attended high school

Did you receive a high school diploma or GED?(required)

Yes No

Please list the names of any secondary institutions (colleges, universities, trade schools, professional schools, etc.), the years you attended, and if you earned a diploma or degree.

Please list any other education you have received that you feel may better assist AmStar EMS.

Please list all certifications possessed. Only list certifications that are not expired.

Please list your work experience for the last three positions you held below, including the most recent first.

Job #1: Company Name

Phone #

Supervisor’s Name

Employment Dates

Pay or Salary

Reason for Leaving

Job #2: Company Name

Phone #

Supervisor’s Name

Employment Dates

Pay or Salary

Reason for Leaving

Job #3: Company Name

Phone #

Supervisor’s Name

Employment Dates

Pay or Salary

Reason for Leaving

May we contact your previous employers?(required)

Yes No

Have you ever been in the armed forces?(required)

Yes No

Have you ever been in the Reserves or the National Guard?(required)

Yes No

Please provide the name and phone number of two references other than relatives or employers.

Please Read Carefully

In exchange for the consideration of my job application by AmStar EMS, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefits plans, policy statements, and the like as they may exist from time to time, or other company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of AmStar EMS, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Director/Owner of AmStar EMS. Both the undersigned and AmStar EMS may end the employment relationship at any time, without specified notice or reason. If employed, I understand that AmStar EMS may unilaterally change or revise their benefits, policies, and procedures, and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without previous notice. I hereby give AmStar EMS permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release AmStar EMS from any liability as a result of such contract.

I also understand that my employment with AmStar EMS shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with AmStar EMS is terminable at will for any reason by either party.

Employee Electronic Signature

Date (YYYY-MM-DD)

If you are called for an interview, please bring all of your current certifications, including National Registry, Alabama state EMS licensure, CPR, PALS, ACLS, EVOC, and any other certifications you may have.

AmStar EMS is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with AmStar EMS depends solely on your qualifications.

Thank you for completing this application form and for your interest in AmStar EMS.

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