* = Required Information
Application Information
Education

Special Skills

Describe any specialized training or skills that you possess. (e.g. computer, typing, telemarketing, sales, customer service, etc.)

Work Experience

Starting with your current or most recent job, complete the following for your two most recent jobs.


EMT Advanced EMT Paramedic None
Yes No

Indicate state(s), license number, and reason:

Yes No

Indicate state(s), license number, and reason:


Yes No

Within the past 10 years:

Yes No

For the purpose of verifying driving record information, please indicate your drivers license number below

Yes No

Indicate state(s), license number, and reason:

Professional References

Provide contact information of two Professional references who are not related to you.


APPLICATION ACKNOWLEDGEMENT

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING FOLLOWING PAGE

1. Misrepresentation of Information. I certify that all information given on this application form and in connection with my application for employment is true and correct. I acknowledge and agree that any falsification, misrepresentation or omission of facts supplied by me will result in making this application null and void; and may, if I become employed, result in termination of my employment, regardless of when discovered.

2. Background Investigation. I understand that as part of normal procedure for processing employment applications and employment requests, an inquiry may be made concerning information on my work history, education, character, criminal history, motor vehicle and driving records, credit history, social security number and eligibility to work in the United States. I authorize AmeriPro EMS to make these inquiries, to investigate all statements in this application and to secure any necessary information from all my employers, references, government entities and academic institutions, and I agree to cooperate in this process

3. Employment at Will. I understand and agree that nothing in this Applicant Supplemental Information form, in AmeriPro EMS’s policy statements, personnel guidelines or employee handbook is intended to create an offer of employment or an employment contract between AmeriPro EMS and me. I understand and agree that employment and compensation with AmeriPro EMS will be on an at-will basis, meaning that my employment will be for no definite duration and can be terminated, with or without cause and with or without prior notice, at any time. My signature below certifies that I understand that the foregoing is the entire understanding between AmeriPro EMS and me concerning the duration of my employment and the circumstances under which my employment may be terminated and supersedes all prior arrangements, understandings and representations.

4. Compliance with AmeriPro EMS Work Rules and Policies. I agree that if I am employed I will abide by all work rules and policies of AmeriPro EMS and acknowledge that these rules and policies may be changed, interpreted, withdrawn, or added to by AmeriPro EMS at any time, at AmeriPro EMS’s sole option, and with or without prior notice to me.

I hereby acknowledge that I have read, understand and agree to the preceding statements and to the best of my knowledge and belief, the information on the application form is true and correct. This authorization shall remain on file throughout the duration of my employment relationship with AmeriPro EMS (if any), and shall serve as ongoing authorization for AmeriPro EMS to procure background reports at any time during my employment with AmeriPro EMS (if any).
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