1 - inHealth Employment Application

Date Filing Application*

MonthDayYear
Date
inHealth Employment Application

2700 Valparaiso St. Unit 1711, Valparaiso, Indiana, 46383 219.545.1796 | Ron@IndianaHealth.Care
DispatcherAmbulance OperationsIndustrial EMSCommunity MedicineDeployment ReserveBilling DepartmentOther

MINIMUM QUALIFICATIONS:
- 18 years of age when applying for EMT and or Paramedic
- Active EMT Certification or Paramedic License
- Posses all necessary licenses and certifications
- A Valid Driver’s License with minimal violations
- Successfully complete all pre-employment testing
- Paramedic eligable for Northwest Health Porter Hospital Sponsorship
NREMT's and Paramedics, please still apply and we can help you with reciprocity
If you have any questions, you may contact Ron Donahue 219.545.1796 | Ron@IndianaHealth.Care
Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Email*

Confirmation Emailexample@example.com

Have you submitted an application with inHealth before?*
If yes, give date dates and position.
NoYes
Please provide information describing the circumstances of your employment and your separation of employment*

Have you ever been debarred, suspended, excluded, or otherwise ineligible for participation in federal health care programs? *
If YES, please explain:
Have you ever been convicted of a felony? *
If YES, please explain:
Have you ever been placed on probation? *
If YES, please explain

Education Information*
Institution | Dates | Degrees or Certifications
Experiences, charity work or other personal accomplishments*

Past Employment History 1 of 3
Company Name
Still EmployedOther
Job Title
Hourly Rate of Pay?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Responsibilities
Company Name | Employment Dates | Position | Rate Of Pay | Responsibilities | Reason For Leaving May we contact this employer? If no, please provide the reason why?
YesOther

Past Employment History 2 of 3
Company Name
Still EmployedOther
Job Title
Hourly Rate of Pay?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Responsibilities
Company Name | Employment Dates | Position | Rate Of Pay | Responsibilities | Reason For Leaving May we contact this employer? If no, please provide the reason why?
YesOther

Past Employment History 3 of 3
Company Name
Still EmployedOther
Job Title
Hourly Rate of Pay?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Responsibilities
Company Name | Employment Dates | Position | Rate Of Pay | Responsibilities | Reason For Leaving May we contact this employer? If no, please provide the reason why?
YesOther

Professional References
List the name and telephone number of three references that are not related to you and not former employers. These references should have knowledge of your capability to perform the duties of the position you are seeking
If you have a résumé you would like us to view, please upload here

Browse Files
A résumé is not required to complete this application Cancelof
APPLICANT’S STATEMENT

I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or if I am hired will be cause for immediate dismissal. Unless I noted otherwise, I authorize inHealth to contact all my employment references and other references, as well as the educational institutions I have attended. I further authorize inHealth to inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions. I hereby release inHealth, as well as any person or institution that provides inHealth. with any lawful information about me, from any and all liability whatsoever resulting from any such lawful inquiry, investigation or communication.

I understand that any hiring decision is contingent upon my successful completion of all of inHealth’s lawful pre-employment background check and testing. I agree to execute any forms necessary for inHealth to conduct its established practice.

It is the policy of inHealth to provide equality of opportunity to all persons regardless of race, color, national origin, sex, age or disability. This policy applies to all aspects of our personnel policies, practice and operations. inHealth complies with the Americans with Disabilities Act (ADA). Persons needing accommodations in the recruitment process should notify inHealth in advance. All information contained in or connected with this application will be considered personal and confidential and used only in conjunction with your possible employment by inHealth. Please furnish us with complete information as outlined in this application.

Any misrepresentation on this application whether actual or by omission may disqualify you for consideration of employment by inHealth. and post employment.

In consideration of my employment, I agree by submitting with appilcation to conform to the policies and procedures of inHealth.
Please verify that you are human*
Should be Empty:

Rows	Morning	Evening	Unavailable	Availability Rotates
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inHealth Employment Application

Certification Verification

Past Employment History 1 of 3

Past Employment History 2 of 3

Past Employment History 3 of 3