IL APP - EMT

Personal Information
Name:*

First NameLast Name
Cell Phone Number:*

Area CodePhone Number
Home Phone Number:

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
General Information
Are you eligible to work in the United States?*

YesNo
Preferred Method of Contact:*

Cell PhoneHome PhoneEmail
Do you meet the 125 LBS Lift Requirement?*

YesNo
Desired Location for Employment:*
Requested Employment Schedule:*

Full TimePart Time
What date are you available to start work?:*

MonthDayYear
Date
EMS Credential Information

Don't have your EMT license yet? Go to EMTNOW.org!
Level of EMT Certification:*

EMR - Emergency Medical ResponderEMT-B - Emergency Medical TechnicianEMT-P - ParamedicCCEMT-P - Critical Care Paramedic
What EMS System are you currently in?:*
Not sure? Put N/A.
Illinois Department of Public Health Certifications Number:
Expiration Date:

MonthDayYear
Date
Basic Cardiopulmonary Resuscitation Number (CPR):
Expiration Date:

MonthDayYear
Date
Advanced Cardiac Life Support (Paramedics Only):
Expiration Date:

MonthDayYear
Date
Number of Hours you would like to work per week:*
Ex. 20-hours/40-hours
Employment History

Please list former/current employers with a description of your responsibilities.
Employer 1
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Years Known:*
Position Title:*
Brief Description of Responsibilities:*
May we contact your present employer(s)?:*

YesNo
Employer 2
Name:

First NameLast Name
Phone Number:

Area CodePhone Number
Years Known:
Position Title:
Brief Description:
May we contact your present employer(s)?:

YesNo
Have you worked for Elite before?*

YesNo
How did you hear about us?*
Would you like a Virtual or In-person Interview?*

VirtualIn-Person
Have you ever been the subject of a Hospital System Investigation?*

YesNo
Has the Illinois Department of Public Health ever suspended, revoked or refused to renew your EMT license or taken any other type of disciplinary action against you / or your EMT license including, but not limited to, letter of reprimand, letter of clinical deficiency, advisory letter?*

YesNo
Is there anything else you'd like us to know?
If not, please leave blank.
I represent that I have fully understood the questions above, that my answers are truthful and accurate, and that the omission of any material fact, commission of any statement, and / or any attempt to misrepresent the truth will result in immediate termination.
Please verify that you are human*
Should be Empty: