Application

BASIC INFORMATION

EMERGENCY CONTACT

REFERRAL SOURCE

  Select Referral Source:

     Walk In         Other

     Relative         Employee

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POSITION DESIRED

  Position :

     EMT

     Dispatcher

     Medical Billing

If applying for a full-time position and one is unavailable, are you willing to work part-time? :

Yes No

  Some position within our company may require working overtime,weekends, holidays, etc.
  Can you accommodate this? :

     Yes        No

  Time :

     Full-Time

     Part-Time

     Per-Diem

ELIGIBILITY

  Have you ever been convicted of a crime, have a conviction pending,
  or had a conviction expunged?

     Yes        No

  Do you currently work for another agency or company that could cause
  a conflict of interest if employed by Premier Medical Transport, Inc.?

     Yes        No

Have you ever been known by another name?

Yes No

QUALIFICATIONS/CERTIFICATIONS

EMT-1 :	Certification/License Number :	Expiration :
OC EMS Accreditation :	Certification/License Number :	Expiration :
AHA BLS for Healthcare Providers :	Certification/License Number :	Expiration :
CA Driver's License :	Certification/License Number :	Expiration :
Medical Examiner’s Certificate (DOT - DL51) :	Certification/License Number :	Expiration :
Ambulance Driver's Certification :	Certification/License Number :	Expiration :
Other :	Certification/License Number :	Expiration :
Other :	Certification/License Number :	Expiration :

EDUCATION

Graduate? Yes No

WORK EXPERIENCE (STARTING WITH MOST RECENT)

REFERENCES

ACKNOWLEDGEMENTS

I acknowledge that the all information provided is correct and true to my best ability.

I acknowledge that I will comply with Premier Medical Transport's post-offer examinations (including back safety training, ride alongs, TB testing, drug testing, etc.) if offered a position with Premier Medical Transport.

AUTHORIZATION

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 make any agreement contrary to the forgoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related medical information in a manner prohibited by the American Disability's Act (ADA) and other relevant federal and state laws.