Personal Information
Name:
Present Address:	Address, City, State, Zip
Home Phone Number:
Cell Phone Number:
E-Mail:
Driver's Lic. #:
Referred By:	Select... Friend Instructor College Recruiter Testing Center MEDI-Star Employee Internet Miscellaneous
Emergency Contact
Name, Relationship:
Address:	Address, City, State, Zip
Phone Number:
GENERAL INFORMATION
Have you previously applied here?	No Yes         Date?
Do you have any friends or relatives working us?	No Yes
If so, what is your relationship to them?
Are you 18 years of age or older?	No Yes
Can you provide proof after you are hired that you can legally work in the United States?	No Yes
Have you ever been convicted of a felony or any crime of moral turpitude?	No Yes
If you answered yes above, please explain:
EMPLOYMENT DESIRED
Type of Employment:	Full Time         Part Time
Position Applying for:	Select... EMT-Basic Driver/Attendant EMT-Basic Attendant Only Dispatcher Marketing Representative Paramedic General
Are you currently employed?	No Yes         Salary Desired?
If yes, may we contact your present Employer?	No Yes
EDUCATION, TRAINING, AND EXPERIENCE
High School, City, State: Years: Graduate? Subject Studied: < 1 1 2 3 4 Yes
College, City, State: Years: Graduate? Subject Studied: < 1 1 2 3 4 Yes
University, City, State: Years: Graduate? Subject Studied: < 1 1 2 3 4 Yes
Trade School, City, State: Years: Graduate? Subject Studied: < 1 1 2 3 4 Yes
Additional experience, skills, or training which make you especially suited to work for us:
EMPLOYMENT HISTORY
List all present and past employment starting with most recent
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes     No Reason For Leaving:
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes     No Reason For Leaving:
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes     No Reason For Leaving:
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes     No Reason For Leaving:
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes     No Reason For Leaving:
Employer Name: Phone Number: Address: Address, City, State, Zip Supervisor's Name: Salary: Position and Duties: Dates of Employment: From To May we contact them? Yes    No Reason For Leaving:
GENERAL
List your activities and interests (athletics, hobbies, etc.):
US Military Service or National Guard:	Air Force Army Coast Guard Marines Navy National Guard Reserve Rank
Additional languages that you can speak, read, or write:
How did you hear about us?	Select... Friend Employee Relative Presence at Special Event Internet Search Engine OCEMS Agency EMT School Direct Inquiry Other
REFERENCES
List three persons you have known at least one year. Do not list relatives.
Ref. Name (Last, First): Address: Address, City, State, Zip Phone Number: # of years acquainted Job Title:
Ref. Name (Last, First): Address: Address, City, State, Zip Phone Number: # of years acquainted Job Title:
Ref. Name (Last, First): Address: Address, City, State, Zip Phone Number: # of years acquainted Job Title:
APPLICANT'S CERTIFICATION
I certify that the information contained in this application is true and correct and complete to the best of my knowledge and belief. I understand that any false statement, omission, or misrepresentation of facts in connections with this application can be cause for rejection of my application, or if I am employed, for my dismissal from employment. I also understand that I am required to abide by all rules and regulations of MEDI-Star Ambulance and that I may be required to work overtime hours or hours outside a normally defined work day or week. I hereby authorize investigation of all information contained in this application for employment as well as all information otherwise submitted by me orally or in writing, in connection with my application for employment. In this regard, I authorize MEDI-Star Ambulance to request and obtain information concerning my previous employment and educational background from all of my prior employers and educational institutions which I have attended, information concerning me. I hereby authorize any prior employer or educational institutions which I have attended, to provide information to MEDI-Star Ambulance as may be requested, and I hereby release them and each of them from any and all liability for damages of whatever nature arising from furnishing the requested information. I hereby understand and acknowledge that if I am employed, my employment relationship with MEDI-Star Ambulance is of an "at-will" nature, which means that I may resign at any time and that MEDI-Star Ambulance may discharge me at any time, with or without cause. It is further understood that this "at-will" employment relationship may not be changed by any statement or conduct of any person, unless such change is specifically acknowledged in writing, signed by the President of MEDI-Star Ambulance. I acknowledge that no other promise, agreements or representations have been made contrary to this "at-will" employment agreement, and that this agreement, as acknowledged by my initials below, is the full and complete agreement governing MEDI-Star Ambulance and my rights and obligations concerning termination of my employment. Initials   Above statement will be signed in person at time of interview

If you are having problems submmiting this application
please contact us at (888) 755-1199.