Application for Employment

Lancaster EMS

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Lancaster EMS is an equal opportunity employer. No questions on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of race, color, religion, age, sex, national origin, disability, or any other characteristic protected by law.

Items Requested at Time of Interview

* = Required Fields

PERSONAL INFORMATION: Name (First, Middle, Last): Street: City: State: Zip: Daytime Phone: Evening Phone: Social Security Number: Drivers License # & State: State EMS Cert #: Email: * Have you ever applied for employment with us? Yes No Are you legally allowed to work in the United States? Yes No Are you 19 years of age or older? Yes No Have you ever been convicted of a felony or criminal misdemeanor? Yes No If 'Yes', please explain: Note: A past conviction does not automatically exclude an applicant from being considered for employment. Have you ever worked for Lancaster EMS? Yes No If 'Yes', give reason for leaving?: POSITION APPLIED FOR: ALS BLS Wheel Chair Van Attendant Business Office Call-Taker/Dispatcher Other Are you able to work:       Days Evenings Nights Weekends 12-Hour Shifts Rotating Shifts Overtime Holidays Are you available to work overtime? Yes No EMERGENCY SERVICES HISTORY: Please list any additional emergency services agencies with which you have been affiliated. This should include volunteer and paid/career positions not listed on the previous page. Be sure to provide as much detail as possible regarding contact information for these agencies (complete mailing address and phone numbers). Most Recent Organization Name of Organization: Dates of Affiliation/Employment: From to Address: Phone Number: Supervisor's Name: May We Contact? Yes   No Position Held: Duties Performed: Pay Rate: Reason for Leaving: Previous Organization Name of Organization: Dates of Affiliation/Employment: From to Address: Phone Number: Supervisor's Name: May We Contact? Yes   No Position Held: Duties Performed: Pay Rate: Reason for Leaving: Previous Organization Name of Organization: Dates of Affiliation/Employment: From to Address: Phone Number: Supervisor's Name: May We Contact? Yes   No Position Held: Duties Performed: Pay Rate: Reason for Leaving: EMPLOYMENT HISTORY: Please list all employers not included in the above list of Emergency Services Affiliations, again beginning with the most recent. As above, be sure to provide as much detail as possible. Be sure to account for any periods of unemployment longer than six months. Most Recent Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No Previous Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No Previous Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No REFERENCES: Please list at least three professional references not related to you. Be sure to provide complete addresses and phone numbers. Name Occupation/Title Address Telephone Years Known ADDITIONAL INFO: Have you ever been discharged, asked to resign, or resigned to avoid discharge from any position? Yes No If 'Yes', please explain: Current level of certification: ALS BLS Certification #: Month/Year you began to function at your current level: With what organization: Lancaster EMS: 1829 Lincoln Highway East Lancaster, PA 17602 I certify that all the information provided in this employment application is true and complete to the best of my knowledge. I understand that any false information or omission may disqualify me from further consideration for employment or may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application and authorize any person, school, current employer (unless otherwise indicated below), past employer and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if an offer of employment is extended, it will be contingent upon me successfully passing a pre-placement physical examination, including a urine drug screen, to determine my ability to perform the essential functions of the position for which I have applied. I consent tot the release of any or all medical information as may be deemed necessary to make this judgment. I further understand that any offer of employment will also be contingent upon the results of a Pennsylvania State Police Criminal Background Check, a Child Abuse History Clearance and a review of my Motor Vehicle Record (separate forms will be utilized to obtain consent for these requests). I understand that neither this application, any segment of the hiring process nor any subsequent offer of employment will constitute a contract of employment nor guarantee employment for any definite period of time. If hired, I understand that Lancaster EMS maintains a policy for "Employment at Will" and that continued employment is based upon the mutual consent of employer and employee. Likewise, said employment may be terminated at any time by either the employer or the employee with or without notice. My signature attests that I have read, understand, and agree to each of the above statements and conditions. Name/Signature: *    Date:   2/22/2012 May we contact your current employer? Yes   No   Not Currently Employed Verify: In order to minimize abuse/spam, please enter the text you see into the input field below. The text is case-sensitive (all upper case, letters and numbers only). Enter code below as shown: * I have read, understand, and agree to each of the above statements and conditions.