LINCOLN EMS - HAMLIN WEST VIRGINIA
Employment Application
Biographical Information
Full Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Number
*
Cell Number
Your E-Mail Address
Do you have a valid drivers license?
*
Yes
No
How many years have you had a drivers license?
*
Any restrictions or points on your drivers license?
*
Yes
No
Restrictions or Points, explain below.
Restrictions or Points may not prevent employment but will be evaluated during the application process.
Position Applying For
Please Select
Administrative Assistant
Secretary
Mechanic
EMT-Paramedic
EMT-Advanced
EMT-Basic
Volunteer (CPR Driver)
Other
EMS Certification
State:
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Certification Number:
NREMT Number:
Expiration Date
-
Month
-
Day
Year
Date Picker Icon
Current Certifications
Check all that apply
EMT
EMT Advanced
Paramedic
CCT Paramedic
CPR
ITLS
ACLS
PEPP
EVOC
AMLS
PHTLS
Position Applying For:
EMT
EMT Advanced
Paramedic
CPR Driver
Administrative Assistant
Secretary
Mechanic
Other
Other:
Full Time / Part Time
Full Time
Part Time
Date Available
-
Month
-
Day
Year
Date Picker Icon
Who referred you to us?
First Name
Last Name
Are you a citizen of the United States?
Yes
No
If no, Are you authorized to work in the U.S. ?
Yes
No
Have you ever worked for this company?
Yes
No
If yes, when?
Have you ever been convicted of a felony?
*
Yes
No
If yes, Explain
Social Media Accounts
Screen names for any social media accounts you currently use
Account Name
Facebook
Twitter
Instagram
YouTube
TikTok
Education
High School
From
-
Month
-
Day
Year
Date Picker Icon
To
-
Month
-
Day
Year
Date Picker Icon
Did you graduate?
*
Yes
No
College
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
From
-
Month
-
Day
Year
Date Picker Icon
To
-
Month
-
Day
Year
Date Picker Icon
Did you graduate?
Yes
No
Degree
References
1. Full Name
*
First Name
Last Name
Relationship
Company Name
Phone Number
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
2. Full Name
*
First Name
Last Name
Company Name
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
3. Full Name
*
First Name
Last Name
Company Name
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Previous Employment
1. Company
*
Phone Number
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From:
-
Month
-
Day
Year
Date Picker Icon
To:
-
Month
-
Day
Year
Date Picker Icon
Reason for Leaving
May we contact your previous Supervisor for a reference?
Yes
No
2. Company
*
Phone Number
*
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From:
-
Month
-
Day
Year
Date Picker Icon
To:
-
Month
-
Day
Year
Date Picker Icon
Reason for Leaving
May we contact your previous Supervisor for a reference?
Yes
No
Disclaimer and Signature
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
-
Month
-
Day
Year
Date Picker Icon
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