EMPLOYMENT

First Name

Last Name

Address

Phone

Social Security Number

Are you eligible for employment in the United States? Required

Yes

Have you ever applied with our organization in the past? Required

Yes

Do you have any relatives employed with our organization? Required

Yes

If so, please list name and relationship:

Have you ever been employed with our organization? Required

Yes

If so, please list dates:

Vehicle Operator Information

Driver's License #:

Expiration Date:

At any time during the past seven (7) years, have you ever been denied a driver's license or been convicted of a moving vehicle traffic offense, including but not limited to, driving under the infuence or reckless driving? Required

Yes

If so, please explain:

Have you ever had automobile insurance cancelled or revoked or have you ever been refused automobile insurance? Required

Yes

If so, please explain:

Insurance Company Name

Policy #

Have you ever been arrested or detained by law enforcement personnel? Required

Yes

Have you ever been convicted, pled guilty, or no contest to a felony or misdemeanor? Required

Yes

Have you ever been fingerprinted for any reason? Required

Yes

Have you ever been convicted of a domestic crime? Required

Yes

If you answered 'Yes' to any of the questions above, please explain:

Emergency Medical Care Information

Emergency Medical Agencies Affiliated With (Present and Past)

Attach additional sheets if needed.

Upload File

Upload supported file (Max 15MB)

Please list Organization, Position, Dates, Supervisor and Contact Information

Training / Certification

Please list all training and certifications including: EMR, EMT, Paramedic, PHRN, CPR, ACLS, PALS, BTLS/ITLS,PHTLS, EVDT, Other

Medical Command Information

(Paramedics Only)

Do you currently have Medical Command Authorization?

Yes

If yes, your Medical Command Physician will be contacted for reference.

Please list Hospital, Address, Medical Command Physician and Contact Information

Has your Medical Command ever been suspended or revoked?

Yes

If yes, please list the details including dates, hospital, Medical Command Physician and reason(s) below:

Education | Military | Employment History

Please upload resume here.

Upload File

Upload supported file (Max 15MB)

Please list any other professional or volunteer experience which may add to your qualifications as an employee for our organization.

Would there be any problem with us contacting your current employer for a job reference?

Yes

If yes, please explain:

Have you ever been disciplined or terminated for reckless driving?

Yes

Have you ever been placed on probation or terminated for excessive absenteeism?

Yes

Have you ever been disciplined or terminated for insubordination?

Yes

Have you ever been disciplined or terminated for violation of safety rules?

Yes

Have you ever been disciplined or terminated for assault or fighting?

Yes

Have you ever been disciplined or terminated for harassment?

Yes

Have you ever been disciplined or terminated for patient abuse?

Yes

Have you ever been disciplined or terminated for alcohol or drug related activity at work?

Yes

If yes to any of the above, please explain:

"Yes" answers will not necessarily disqualify you for employment.

References

References cannot be relatives and must have known you for a minimum for one year.

Personal References: Please list Name, Affiliation, Job Title and Contact Information

EMS References: Please list Name, Agency, Job Title and Contact Information (copy)

Health Record

Do you have any pre-existing physical conditions that may affect you in the performance of your duties as an employee of Hollidaysburg American Legion Ambulance?

Yes

If yes, please describe:

Do you require any special accommodations to perform the essential functions of the position for which you are applying?

Yes

If yes, please list:

Terms of employment status include successful completion of a physical examination, lifting and moving test and drug test. Are you willing to undergo a physical examination, lifting and moving and drug test to prove you are physically able to perform the tasks of the job for which you have applied?

Yes

I hereby certify that the statements contained herein are true and correct to the best of my knowledge. I grant Hollidaysburg American Legion Ambulance Service (HALAS) permission to verify such answers and investigate all references. I understand that any false statements on this application may be considered significant cause for rejection of this application or for termination if discovered subsequent to my employment status. I authorize my former employer(s) and other individuals to give information concerning me and I release them and their companies from any liability whatsoever. Required

I agree

Application Date

NOTE: This application is void after six (6) months. If you have not been hired/contacted within that period of time and are still interested in being considered for employment status, you must reapply.

Thanks for submitting! We will be intouch with you shortly!

814-695-1421

Thank you for your interest in joining our team!

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The statements made herein are subject to verification to determine your qualifications for employment consideration.

H.A.L.A.S. Job Application