Ambulance Service Inc

Name*

First Middle Last

Present Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Is your current address different from your permanent address?*

No
Yes

Permanent Address

Street Address Address Line 2 City State ZIP Code

Are you 18 years or older?*

Yes
No

Are you either a U.S. citizen or an alien authorized to work in the U.S.?*

Yes
No

Have you ever worked or attended school under another name?*

Yes
No

What was the name?*

Have you ever been convicted of a crime?*

Yes
No

Please give details, including date(s): A “yes” answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.*

Have you ever been convicted of any violation of any federal, military, state or local laws (excluding non-criminal traffic violations)?*

Yes
No

Have you ever had any license, certification, or right to practice denied or surrendered, or disciplined with suspension, reprimand, probation, revocation, or any other method of discipline in North Dakota or Minnesota or any other state or jurisdiction?*

Yes
No

Are you the subject of any pending investigation, administration sanction proceeding, hearing, trial or similar action by an agency or board that has granted or denied you a license, certification, or right to practice in any regulated occupation, trade or profession in ND or MN or in any other state or jurisdiction?*

Yes
No

Have you ever been sanctioned by the Office of Inspector General (OIG)? (Medicare, Medicaid)*

Yes
No

Position Desired*

National Registry #

Minnesota License #

North Dakota License #

Date You Can Start

Hourly rate/monthly salary desired

Do you prefer:*

Full-time
Part-time

If part-time, hours per week desired

Hours you are available to work*

Days of the week you are available to work

Are you able to work weekends? (if required for the position for which you are applying)*

Yes
No

Are you able to work holidays? (if required for the position for which you are applying)*

Yes
No

Are you able to work nights? (if required for the position for which you are applying)*

Yes
No

Are you available to work overtime?*

Yes
No

Have you previously worked for this company?*

Yes
No

Start Date*

End Date*

Reason for leaving

Former supervisor(s) at this company

How did you learn about this opening?*

High School Attended*

Did you graduate?*

Yes
No

Technical/College/University School*

Did you graduate?*

Yes
No

Course of Study

Other education or training

Can you type?*

Yes
No

Words Per Minute?

Are you familiar with personal computers?*

Yes
No
PC
Mac

What computer programs are you familiar with?*

Military Experience Branch of Service

Military Start Date

Military End Date

Military Experience Rank at Discharge

Military Experience Education and Training

Please list all previous employment, beginning with the most recent*

Employer #1*

Employer #1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer #1 Start Date*

Employer #1 End Date*

Employer #1 Position Held*

Employer #1 Reason for Leaving*

Employer #1 Supervisor's Name & Title*

May we contact Employer #1?

Yes
No

Employer #1 Description of duties

Employer #2*

Employer #2 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer #2 Start Date*

Employer #2 End Date*

Employer #2 Position Held*

Employer #2 Reason for Leaving*

Employer #2 Supervisor's Name & Title*

May we contact Employer #2?

Yes
No

Employer #2 Description of duties

AUTHORIZATION AND ACKNOWLEDGMENTS -- I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that if I am employed, any false statements on this application may be grounds for dismissal. I authorize investigation of all statements contained in this application. I also grant permission to contact all references listed above, and authorize them to release all information concerning my previous employment and any other pertinent information these references might have, personal or otherwise. I release all parties from all liability for any damage that may result from furnishing this information to you. I understand and agree that, if hired, my employment is for no definite period and may be terminated at any time and without prior notice -- Applicant Signature*

Type your name to sign

Additional Comments

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IF YOU HAVE AN EMERGENCY, DIAL 911

(218) 641-0385

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