Hollidaysburg American Legion Ambulance

E.M.R.S. Inc.
801 Scotch Valley Road
Hollidaysburg Pa 16648
(814) 695-1421

Click here for a Printable PDF Application.

HALAS Inc.
801 Scotch Valley Road
Hollidaysburg Pa 16648
(814) 695-1421

Click here for a Printable PDF Application.

HALAS Inc. 801 Scotch Valley RoadHollidaysburg Pa 16648 (814) 695-1421 On-Line APPLICATION FOR EMPLOYMENT
Position Applied for
Date of Application
Wage Desired
Last Name
First Name
Middle Name
Address (Number)
Street
City
State
Zip
Telephone Number(s)
Pager
Social Security Number
What shift(s) are you available?	Day Evenings Nights
Have you ever applied here before?	Yes No
Have you ever worked for us before?	Yes No
Are you currently employed?	Yes No
May we contact your present employer?	Yes No
Which would you prefer?	Full-time Casual Part-time
Do you believe you would be able to perform the essential functions for the job you are applying?	Yes No
Are you at least 18 years old?	Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?	Yes No
On what date would you be available for work?
Have you ever been convicted of a Felony?	Yes No

Have you ever had your license, permit, orprivileges to operate a motor vehicle denied, suspended, or revoked?	Yes No
If yes, Give details and dates:

Have you had any traffic convictions within the last 5 years? (Other than parking)	Yes No
If yes, please explain:

Have you had any vehicle accidents within the last 5 years? (including at-fault and Not at-fault)	Yes No
EDUCATION
	School Name/Location	Level Completed
High School		1 2 3 4
College		1 2 3 4 5 6 7 8
Other
Diploma/Degree
Course of Study
PREVIOUS WORK HISTORY: Start with your current or last employer
Employer
Dates Employed
Telephone Numbers:
Address:
Job Title:
Supervisor(s):
Reason for Leaving:
Work Performed:

Employer
Dates Employed
Telephone Numbers:
Address:
Job Title:
Supervisor(s):
Reason for Leaving:
Work Performed:

Employer
Dates Employed
Telephone Numbers:
Address:
Job Title:
Supervisor(s):
Reason for Leaving:
Work Performed:

References:
Name
Phone Number
Address

Name
Phone Number
Address

Name
Phone Number
Address
* Hollidaysburg American Legion Ambulance Service Inc. considers all applicantsfor all positions, in accordance with Title VII of the Civil Rights Act of 1964, as amended, and the American With Disabilities Act of 1990, and the AgeDiscrimination in Employment Act of 1967, as amended, which prohibits discrimination in the recruitment, selection, and hiring of employees. HALAS is anequal opportunity employer.
R.N./Health Professional
Paramedic
Emergency Medical Tech
Certification Number(s):
State:
Expiration Date:
Do you have a PA drivers license:	Yes No	Expiration Date:
Paramedics/Health Professionals: Are you eligible for medical command:	Yes No
Have you ever had limitations or restrictions applied to your Medical Command Status:	Yes No
If Yes, Explain:

Do you have:	E.V.O.C.	Yes No
	PHTLS/BTLS	Yes No
	P.A.L.S.	Yes No
	A.C.L.S.	Yes No
	C.P.R	Yes No
	Any instructor certifications (list):	Yes No
	C.C.E.M.T.P.	Yes No
	National Registry	Yes No
-List any additional certifications that are job related or might aid in ourdecision to hire you.

*****Note: Copies of certificates must accompany application with expiration datesvisible. Copy of Valid PA drivers license must be provided with certificates. Applications will be considered VOID if only application is submitted to management, UNLESS a priorarrangement was made. I certify that the answers given are true and complete to the best of my knowledge. I hereby release the management and/or designee of HALAS Inc. from any and all liabilityregarding inquiries made in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview may result in my immediate discharge from employment. Ialso understand that I am required to abide by all rules, regulations, and StandardOperating Procedures of HALAS Inc.
Signature:
Date: