Employment Application – Dauntless Hook & Ladder Ambulance League

DH&L considers applications for employment without regard to race, color, national origin, ancestry, religion, sex, age, disability, political belief, military service, or any other protected class. DH&L IS A DRUG-FREE WORKPLACE!

Personal Information

Name: *

First

Middle

Last

Date: *

Social Security Number *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Other Phone:

Email *

Are you at least 18 years of age? *

Date available to start: *

Hours Requested: *

Full Time
Part Time
Volunteer

How did you find out about this position? *

Do you have any relatives working here? If yes, please list. *

Position Information

Positions you are applying for: *

Have you ever worked for this organization?

If yes, please list dates:

Prior position(s) here:

Reason(s) for leaving:

Certification Information

EMT Certification number:

EMT Expiration Date:

EMT-P Certification number:

EMT-P Expiration Date:

CPR Expiration Date:

ACLS Expiration Date:

PALS Expiration Date:

EVOC/EMSVO Expiration Date:

Work Requirements and General Information

Are you eligible to work in the U.S.? *

Do you have a valid driver's license? *

Issued by what state? *

Driver's license number: *

Class:

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

Have you ever been convicted or pled guilty or no contest to a felony or misdemeanor, including a DUI or similar offense, had any moving violations, or had your license revoked or suspended? *

If yes, explain:

Employment history

(List your last three employers or volunteer activities, starting with the most recent)

Employer 1

Job title:

Supervisor name:

First

Last

Start Date:

End Date:

Salary:

Job description:

Employer's telephone number:

May we contact?

Reason for leaving:

Employment History Second Job

Employer 2

Job title:

Supervisor name:

First

Last

Start Date:

End Date:

Salary:

Job description:

Employer's telephone number:

May we contact?

Reason for leaving:

Employment History Third Job

Employer 3

Job title:

Supervisor name:

First

Last

Start Date:

End Date:

Salary:

Job description:

Employer's telephone number:

May we contact?

Reason for leaving:

Military

Branch of Service

Date began:

Date ended:

Rank and Duties:

Date discharged:

Location:

Past Employment

Have you ever been?

Disciplined or terminated for reckless driving? *

Placed on probation or terminated for excessive absenteeism? *

Disciplined or fired for insubordination? *

Disciplined or fired for violation of safety rules? *

Disciplined or fired for assault or fighting? *

Disciplined or fired for harassment? *

Disciplined or fired for patient abuse? *

Disciplined or fired for alcohol or drug related activity at work? *

If you answered yes to any of the 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: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Years completed: *

Did you graduate? *

If not, highest grade completed:

Have you received your GED?

Education and Training - College

College Name:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Years completed:

Did you graduate?

If not, highest year completed:

Degree

Major

Education and Training - Other School/Training

School Name:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Years completed:

Did you graduate?

If not, highest year completed:

Certificate:

Expiration date:

License:

Expiration date:

Other Information

EMS/Fire service related training not listed above:

EMS/Fire/Professional affiliations not yet listed:

Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know when considering your application:

References

List three persons, other than relatives, who have knowledge of your work experience and/or education.

First Reference: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation: *

Years Known: *

Phone *

Second Reference: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation: *

Years Known: *

Phone *

Third Reference: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation: *

Years Known: *

Phone *

Supporting Documents File Upload

Applicants must include their criminal background check and child abuse clearances with application. Extra documents may be emailed to opsmgr80@gmail.com.

File Upload

Acknowledgment

I certify that the information l 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 a 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 the Company 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 either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or contract for employment. If offered a position and 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. l 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 the Company as a condition of my employment, and I hereby give my consent to the release of all information which the Company 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 this Company. l hereby authorize the Company 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, child abuse clearance check, and other such inquiries. I release the company and all informants from any 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 the Company may be terminated. I understand that by entering my name, I am legally representing my signature. Submission of this form cannot be stopped once the button has been pressed.

Signature *

Date / Time *

Captcha *