Emergency Ambulance Service · Care & Comfort Ambulette

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State:

Zip Code:

Within the last 3 years

Address:

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Zip Code:

Phone #:

Driver License #:	*
State:	*
Expiration:	*
I do not have a license:	(Drivers License information is not required if you do not have a license)

List all in the last 3 years

List all in the last 3 years

By sending this form I understand that my driving record will be verified by the Department of Motor Vehicle.

Position Applying For:	EMT EMT-CC A-EMT MVO (Ambulette) *
EMT/AEMT Certification #:	(None for MVO)
Expiration:	*
# Of Full Time Years Experience:
Have you ever worked for us in the past?	Yes No
If yes, reason for leaving:
Are you currently employed?	Yes No
By whom?
May we contact your present employer?	Yes No
May we contact any of your previous employers?	Yes No
Have you ever been convicted of a felony?	Yes No *
If yes, or pending specify:
Are you a US citizen/permanent resident?	Yes No *
If no, do you have a working permit?	Yes No
Have you served in the US military services?	Yes No
If yes, branch:
Discharged Date/Reason:

Minimum 3 not relatives

City:

State:

Zip Code:

City:

State:

Zip Code:

City:

State:

Zip Code:

Other School Years Completed:
City:
Name of School:
Graduated?	Yes No

Your information will not be shared with anyone, and is only sent to the Chief of Operations.

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