Medic Employment Application

EMPLOYMENT HISTORY

Are you currently employed?*

Yes No

May we contact your employer?

Yes No

If NO, why?

Employer Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Job Description and Duties

Start Date

End Date

Supervisor's Name

Reason for leaving

Employer Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

May we contact this employer?

Yes No

If No, why?

Start Date

End Date

Supervisor's Name

Job Description and Duties

Reason for leaving?

Name of Employer

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

May we contact this employer?

Yes No

If No, why?

Supervisor's Name

Job Description and Duties

Start Date

End Date

Reason for Leaving

Employer name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

May we contact this employer?

Yes No

Supervisor's Name

Job Description and Duties

Start Date

End Date

Reason for Leaving?

MILITARY SERVICE

Have you served or are you currently serving in the Armed Forces of the United States?*

Yes No

Have you obtained any special skills or abilities as the result of service in the military that are applicable to the position you are applying for?

Yes No

If Yes, describe

REFERENCES

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Please Read Carefully, Initial Each Paragraph and Sign Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge and I have read and fully understand the questions asked in this application. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Medic Ambulance Service to thoroughly investigate my references, work record, education, credit report and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between the company and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designed representative.

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid drivers license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state in which I reside. I further agree and give permission for Medic Ambulance Service to check my Motor Vehicle Records for insurability purposes.

If employed by Medic Ambulance Service, I understand and agree that the Company, to the fullest extent permitted by Federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement, as well as an agreement to arbitrate.

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action up to and including immediate dismissal.

If hired, I agree to conform to the rules and regulations of the Company, and I understand that the Company has complete discretion to modify such rules and regulations at any time as allowed by law of contractual requirement, except that the Company will not modify its policy of employment at will where applicable.

Authorization for Background Investigation

I authorize Medic Ambulance Service to conduct a background investigation (to include a criminal background search, “Megan’s Law” inquiry, and previous employment verification) on me for possible employment purposes.

Signature

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DRIVING EXPERIENCE

Driver's License Number

Issuing State

Special Licenses (specify)

Have you driven emergency equipment before?*

Yes No

Explain the nature of driving and type of vehicle

Moving violations in the last 5 years (list type, location and date)

Accidents in the last 5 years (list nature, location and date)

Have you ever had a license, or privilege to operate a vehicle

Denied Suspended or Revoked

If Yes to either question, please explain in detail

TO BE READ AND SIGNED BY APPLICANT

I understand that misrepresentation of information given above shall be considered an act of dishonesty. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

COMBINED DISCLOSURE NOTICE AND AUTHORIZATION

REGARDING BACKGROUND CONSUMER REPORTS

A consumer report and/or investigative consumer report including information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with the employer. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the employer. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made. Upon timely written request of the personnel department of the employer, and within five (5) days of the request, the name, address and phone number of the reporting agency and the nature and scope of the investigative consumer report will be disclosed to you. Before any adverse action is taken, based in whole or in part on the

Information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, and a summary of your rights under the Fair Credit Reporting Act.

REASONABLE ACCOMMODATION

Title I of the Americans with Disabilities Act of 1990 (the "ADA") requires an employer to provide reasonable accommodation to qualified individuals with disabilities who are employees or applicants for employment, unless to do so would cause undue hardship. "In general, an accommodation is any change in the work environment or in the way things are customarily done that enables an individual with a disability to enjoy equal employment opportunities." There are three categories of "reasonable accommodations":

"(i) modifications or adjustments to a job application process that enable a qualified applicant with a disability to be considered for the position such qualified applicant desires; or

(ii) modifications or adjustments to the work environment, or to the manner or circumstances under which the position held or desired is customarily performed, that enable a qualified individual with a disability to perform the essential functions of that position; or

(iii) modifications or adjustments that enable a covered entity's employee with a disability to enjoy equal benefits and privileges of employment as are enjoyed by its other similarly situated employees without disabilities."

The duty to provide reasonable accommodation is a fundamental statutory requirement because of the nature of discrimination faced by individuals with disabilities. Although many individuals with disabilities can apply for and perform jobs without any reasonable accommodations, there are workplace barriers that keep others from performing jobs which they could do with some form of accommodation. These barriers may be physical obstacles (such as inaccessible facilities or equipment), or they may be procedures or rules (such as rules concerning when work is performed, when breaks are taken, or how essential or marginal functions are performed). Reasonable accommodation removes workplace barriers for individuals with disabilities.

Reasonable accommodation is available to qualified applicants and employees with disabilities. Reasonable accommodations must be provided to qualified employees regardless of whether they work part- time or full-time, or are considered "probationary." Generally, the individual with a disability must inform the employer that an accommodation is needed

AUTHORIZATION

You hereby authorize and request, without any reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish the background check company with any and all background information in their possession regarding you, in order that your employment qualifications may be evaluated.

Signature

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REQUIRED ATTACHMENTS

REQUIRED ATTACHMENTS

EMT (Required with submission):

5 year DMV Printout (within 2 weeks from date on application)
Valid California Driver License
TB (within 1 year)
Hepatitis B (3 sets)
Valid Ambulance Driver License
Current Medical Exam Card
EMT Accreditation Card (County or State)
Current BCLS Card

PARAMEDIC(Required with submission)

5 year DMV printout (within 2 weeks from date on application)
Valid California Driver License
TB (within 1 year)
Hepatitis B (3 sets)
Current Ambulance Driver License
Current Medical Exam Certificate
Current BCLS Card
Current ACLS Card
Current PEPP or PALS Card
Current ITLS or PHTLS Card
Current State of California Paramedic License

REGISTERED NURSE (required with submission)

5 year DMV printout (within 2 weeks from date on application)
Valid California Driver License
TB (within 1 year)
Hepatitis B (3 sets)
Current BCLS Card
Current ACLS Card
Current PEPP or PALS Card
Current State of California RN License

SUPPLY SERVICE TECHNICIAN (SST) (Required with submission)

5 year DMV printout (within 2 weeks from date on application)
Valid California Driver License
TB (within 1 year)

OTHER APPLICANTS (Required with submission)

HS Diploma or GED
MS Office (Preferred)
Medical Terminology (Perfered)

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