Application for Employment 2020

First Responders, Inc Application for Employment (Pre-employment Questionnaire) (An Equal Opportunity Employer)
DATE

Month Day Year
Date
Name:
Social Security No.
Telephone:
Address

Address

Street Address Line 2

City, State, Zip
Position Applying For:
Special Training and/or Certification:
RN license or EMT Cert. Number
Are you a US Citizen or an alien authorized to work in the US?

Yes No
Date of Last Negative TB test or X-Ray (copy will need to be provided)
Have you been convicted of a felony or misdemeanor in the last five years?

Yes No
Yes, explain:

(Please list last five years of work history. Applicants must be 18 years of age and have a clean driving record.

Work History

	Date Employed	Position Held	Employer Name	Employer Address	Employer Phone
1.
2.
3.
4.
5.
6.
7.
8.

Please list your work experience and references. List 2 professional and 2 personal references.

References

	Reference Name	Address	Phone
1.
2.
3.
4.

Have you, within the past five years, been convicted of, or are currently under investigation for any crime of abuse of a vulnerable adult, sexual abuse, incest, first or second degree murder, kidnapping, arson, sexual assault, sexual exploitation of a minor, contributing to the delinquency of a minor, commercial sexual exploitation of a minor, felony offenses involving distribution of marijuana or narcotic drugs, theft, robbery, a dangerous crime against children, child abuse, sexual conduct with a minor, molestation of a child, manslaughter, aggravated assault, domestic violence, fraud and fraudulent schemes, assault within the lastfive years or possession of a dangerous narcotic within the last five years?

Yes No
This position requires you to read and write English. Do you understand English in verbal and written forms?

Yes No
Do you have any mental condition which may prevent you from performing the duties of this position?

Yes No
This position requires occasional heavy lifting and moving of people, etc. Do you have any physical condition which may prevent you from performing the duties of this position?

Yes No
As part of providing a safe work environment, First Responders, Inc. may perform a pre-employment drug screen. Additionally, First Responders, Inc may perform periodic random drug screening.

To the best of my knowledge, all information provided on this application is true. I understand that providing false information on this application is grounds for termination.
Applicant's Signature:

Clear
Date
Should be Empty:

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