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Personal Information

Name:

Last: * First: * Middle: Maiden:

Present Address:

Street Address: * Apartment/Unit: City: * State: * Zip Code: *

Telephone:

Home: Cell:

Personal Information:

Email:

Employment Information Position Applied For: Salary Desired: $

Days/Hours Available to Work:
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How many hours can you work weekly?

Can you work nights?

Yes No

Can you work holidays?

Yes No

Employment Desired:
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When are you available for work?

Education & Other Information

Type of School	Name of School	Location (Complete mailing address)	No. of Years Completed	Major & Degree
High School
College
Bus. or Trade School
Professional School

Have you ever been convicted of a crime?

Yes No

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, senetence(s) imposed, and type(s) of rehabilitation.

Do you have a driver's license?

Yes No What is your means of transportation to work?

Driver's License Information

Number: State of Issue:

Type:

Operator Commercial (CDL) Chauffeur Expiration Date:

Have you had any accidents during the past three years?

Yes No How many?

Have you had any moving violations during the past three years?

Yes No How many?

Please list two references other than relatives or previous employers

Name: Position: Company: Address: Telephone:

An application form sometimes make it difficult for an individual to adequately summarize a complete background. Use the space below to add any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Military

Have you ever been in the armed forces?

Yes No

Are you now a member of the National Guard?

Yes No Specialty: Date Entered Discharge Date:

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of Employer: Name of Last Supervisor:

Employment Dates

From: To:

Salary

Start: Final: Phone Number: Your Last Job Title: Reason for leaving (be specific): List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer: Name of Last Supervisor:

Employment Dates

From: To:

Salary

If you need to list additional positions, please use the following textbox.

Please list the following certifications

Emergency Medical Technician (EMT)	Expires:	Years: Months:
Cardiopulmonary Resuscitation (CPR)	Expires:
Hazardous Materials
Incident Command System (ICS) (NIMS)
Weapons of Mass Destruction (WMD)

List all other pertinent certifications:

Application Form Waiver

Please read carefully.

In exchange for the consideration of my job appication by Ironbound Ambulance Squad (hereinafter called "the Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, standard operating procedures, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Ironbound Ambulance Squad, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and Ironbound Ambulance Squad may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their policies and procedures and such changes may include reduction in benefits.

I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission o facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as random testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successfull passing of job-related physical examinations.

I understand that (1) the Company has a pre-employment background check policy; (2) consent to and compliance with such policy is a condition of my employment. I further understand that employment will be based on the successful passing of the background check.

I understand that, in connection with the routine processing of your employment application, the Company may request form a consumer reporting agency an investigate consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of one hundred eighty (180) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of Applicant: * Date:

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.