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Personal Information

First Name:

Last Name:

Middle Name:

Social Security Number:

Address 1:

Address 2:

City:

State:

Zip Code:

Email:

Home Phone:

Alt Phone:

Date Available to Start:

Hours Requested:

 Full-time Part-time

Position Information

Are you at least 21 years of age?

 Yes No

Position(s) applying for:

Have you ever applied or been employed by the company before?

 Yes No

Date:

Prior Position:

Reason for Leaving:

Certification Information

Certification Certification Number Expiration Date Certifying Agency
CPR
EMT / EMT-P
National Registry
PALS
ACLS
BTLS
EMD
CDL
Other

General Information

Do you have a valid drivers license?  Yes No

Class:

State:

Driver’s License #:

List all moving violations (convictions) and accidents and any suspensions or revocations of your license in the last five years:

Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, Including a DUI/DWI or similar offense, had any moving violations, or had your license Revoked or suspended?  Yes No

Please Explain:

Please Answer the Following Questions

How did you find out about this position:

Do you have any relatives or friends working here?  Yes No

Please List:

Employment History (List your last three employers starting with the most recent)

Employer 1

Employer:

Job Title:

Supervisor:

Start Date:

Salary:

End Date:

Salary:

Job Description:

Employer Phone #:

May we contact?  Yes No

Reason for Leaving:

Employer 2

Employer:

Job Title:

Supervisor:

Start Date:

Salary:

End Date:

Salary:

Job Description:

Employer Phone #:

May we contact?  Yes No

Reason for Leaving:

Employer 3

Employer:

Job Title:

Supervisor:

Start Date:

Salary:

End Date:

Salary:

Job Description:

Employer Phone #:

May we contact?  Yes No

Reason for Leaving:

Employer 4

Employer:

Job Title:

Supervisor:

Start Date:

Salary:

End Date:

Salary:

Job Description:

Employer Phone #:

May we contact?  Yes No

Reason for Leaving:

Past Employment

Have you ever been:

Disciplined or terminated for reckless driving?  Yes No

Placed on probation or terminated for excessive absenteeism?  Yes No

Disciplined or fired for insubordination?  Yes No

Disciplined or fired for violation of safety rules?  Yes No

Disciplined or fired for assault or fighting?  Yes No

Disciplined or fired for harassment?  Yes No

Disciplined or fired for patient abuse?  Yes No

Disciplined or fired for alcohol or drug related activity at work?  Yes No

If you answered yes to any questions above, please explain:

Answers of Yes for any of the above questions will not necessarily disqualify you from employment.

Education and Training

High School:

Name:

Years Completed:

Address 1:

Address 2:

City:

State:

Did you graduate?  Yes No GED

College

Name:

Years Completed:

Address 1:

Address 2:

City:

State:

Did you graduate?  Yes No

Technical School

Name:

Years Completed:

Address 1:

Address 2:

City:

State:

Did you graduate?  Yes No

Other School/Training

Name:

Years Completed:

Address 1:

Address 2:

City:

State:

Did you graduate?  Yes No

EMS/Fire service related training not listed above::

References

List three professional references who have knowledge of your work experience and/or education

Reference 1

Name:

Address 1:

Address 2:

Occupation

Years Known

Phone Number

Reference 2

Name:

Address 1:

Address 2:

Occupation

Years Known

Phone Number

Reference 3

Name:

Address 1:

Address 2:

Occupation

Years Known

Phone Number

List two personal references, other than relatives, that have known you for at least three years outside work

Reference 1

Name:

Address 1:

Address 2:

Occupation

Years Known

How do they know you?

Phone Number

Reference 2

Name:

Address 1:

Address 2:

Occupation

Years Known

How do they know you?

Phone Number

I certify that the information I have given on this application is true, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate Mercy Regional Emergency Health Services in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be “at will” and whether I or Mercy Regional Emergency Health Services is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment.

If offered a position at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties.

I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by Mercy Regional Emergency Health Services as a condition of my employment, and I hereby give my consent to the release of all information which Mercy Regional Emergency Health Services deems necessary to determine my ability to perform job duties now or in the future.

I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from Mercy Regional Emergency Health Services.

I hereby authorize Mercy Regional Emergency Health Services to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release Mercy Regional Emergency Health Services and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.

I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded; my employment with Mercy Regional Emergency Health Services may be terminated.

 I Acknowledge the above