Application for Employment

Superior Ambulance Service, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of any characteristics protected by law, including race, color religion, age, sex, national origin, or disability.

PERSONAL:

Name*:
(Last, First, Middle Initial)

Date of Application*:

Email Address*:

Phone Number*: Home Work Cell

Do you possess a valid drivers license? Yes No

Do you possess a valid CDL driver’s license? Yes No

If yes, do you possess passenger endorsement? Yes No

Position desired?*

Type of employment desired?*

Date Available to Start*:

Salary Desired*:

Are you over 18 years old?* Yes No

Are you legally eligible for employment in the United States?* Yes No

(If offered employment, you will be required to provide documentation to verify eligibility)

RECORD OF CONVICTION:

During the last 10 years, have you ever been convicted of a crime other than a minor traffic violation?* Yes No

If yes please describe the nature of the offense, when, where and Disposition:

(A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as your age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)

EMPLOYMENT AT SUPERIOR AMBULANCE:

Have you ever been employed here before? Yes No

If yes please give dates of employment and reason for leaving:

APPLICATIONS TO SUPERIOR AMBULANCE:

Have you ever submitted an application here before? Yes No

Please list any Special Training or Certificates you may possess:

Please list any friends or relatives currently employed by Superior Ambulance Service.

Have your privileges to practice as an EMT/ AEMT ever been suspended or revoked? Yes No
If yes, Please explain:

EMPLOYMENT:

May we contact your current employer?* Yes No

If an employment was under a different name, indicate name:

Job 1

Duties:

Type of employment?*

Number of Hours:

Job 2

Duties:

Type of employment?*

Number of Hours:

Job 3

Duties:

Type of employment?*

Number of Hours:

Job 4

Duties:

Type of employment?*

Number of Hours:

Job 5

Duties:

Type of employment?*

Number of Hours:

If you wish to describe additional work experience:

EDUCATION:

Please indicate education or training that you believe qualifies you for the position you are seeking.

High-school

Number of years completed 1 2 3 4

Diploma Yes No

G.E.D. Yes No

Name

Address

College and/or Vocational School

Number of years completed 1 2 3 4

Name

Address

Major

Degrees Earned

Please List training History

Instructor:

Course Location:

Level of Cert.

Date of Course:

Instructor:

Course Location:

Level of Cert.

Date of Course:

Instructor:

Course Location:

Level of Cert.

Date of Course:

Instructor:

Course Location:

Level of Cert.

Date of Course:

Instructor:

Course Location:

Level of Cert.

Date of Course:

Please list current or previous affiliations with volunteer services (Fire, EMS, Other):

Professional

Type of License(s) Held

Other Professional Memberships

REFERENCES:

Reference #1:

Name:

Address:

Telephone:

Reference #2:

Name:

Address:

Telephone:

Reference #3:

Name:

Address:

Telephone:

APPLICANT’S CERTIFICATION AND AGREEMENT

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to may any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.”

Applicant Name / Electronic Signature*:

Date of Application*:

Contact Us

Superior Ambulance Service, Inc.
Application for Employment

PERSONAL:

RECORD OF CONVICTION:

EMPLOYMENT AT SUPERIOR AMBULANCE:

APPLICATIONS TO SUPERIOR AMBULANCE:

EMPLOYMENT:

Job 1

Job 2

Job 3

Job 4

Job 5

EDUCATION:

High-school

College and/or Vocational School

Please List training History

Professional

REFERENCES:

Reference #1:

Reference #2:

Reference #3:

APPLICANT’S CERTIFICATION AND AGREEMENT

Complete CAPTCHA requirements or your form data may be lost.

Contact Us

Superior Ambulance Service, Inc. Application for Employment

PERSONAL:

RECORD OF CONVICTION:

EMPLOYMENT AT SUPERIOR AMBULANCE:

APPLICATIONS TO SUPERIOR AMBULANCE:

EMPLOYMENT:

Job 1

Job 2

Job 3

Job 4

Job 5

EDUCATION:

High-school

College and/or Vocational School

Please List training History

Professional

REFERENCES:

Reference #1:

Reference #2:

Reference #3:

APPLICANT’S CERTIFICATION AND AGREEMENT

Complete CAPTCHA requirements or your form data may be lost.

Superior Ambulance Service, Inc.
Application for Employment