LINCOLN EMS

	Account Name
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1. Most Recent Company*

Phone Number*

Address

Street Address

Street Address Line 2

CityState

Zip Code

Supervisor

Your Job Title

Starting Salary

Ending Salary

Responsibilities

From:

MonthDayYear

To:

MonthDayYear

Reason for Leaving

May we contact your previous Supervisor for a reference?

YesNo

2. Company*

Phone Number*

Address

Street Address

Street Address Line 2

CityState

Zip Code

Supervisor

Your Job Title

Starting Salary

Ending Salary

Responsibilities

From:

MonthDayYear

To:

MonthDayYear

Reason for Leaving

May we contact your previous Supervisor for a reference?

YesNo

Disclaimer:

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed,  falsified statements on this application shall be grounds for dismissal.    I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all  information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the  company from all liability for any damage that may result from utilization of such information.    I understand that I must submit to a pre-employment and random drug and alcohol screening and failure to successfully pass such test will  result in automatic dismissal of my application and/or termination of my employment.      I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any  specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company  representative.

Referred to Lincoln EMS?

Signature:*

Digital Signature

Date

MonthDayYear

Resume if you have one.

LINCOLN EMS - HAMLIN WEST VIRGINIA

Current EMS Certification

Cards You Hold

Disclaimer and Signature