Galesburg Hospitals’ Ambulance Service

Galesburg Hospitals’ Ambulance Service
2175 Windish Drive – Galesburg, Il 61401
Employment Application
In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but not be limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends. GHAS is an equal opportunity employer.
Name

First NameLast Name
DATE OF APPLICATION

MonthDayYear
Date
Email
example@example.com
TELEPHONE
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IF ABOVE ADDRESS COVERS LESS THAN 5 YEARS, GIVE PREVIOUS ADDRESS
ANY PREVIOUS NAME(S)?
IF YES, IDENTIFY ALL OTHER NAMES INCLUDING MAIDEN NAME
BEST TIME TO CONTACT YOU
DATE AVAILABLE FOR WORK

MonthDayYear
Date
POSITION APPLYING FOR:
EXPERIENCE:
HAVE YOU WORKED FOR OUR COMPANY BEFORE
IF YES, WHEN?
HOW WERE YOU REFERRED
SHIFT PREFERENCE
ARE YOU APPLYING FOR:
RELATIVES OR FRIENDS EMPLOYED IN THIS FACILITY
IF YES: NAME
RELATIONSHIP
ARE YOU A U.S. CITIZEN OR AN ALIEN LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
HAVE YOU EVER BEEN CONVICTED OF, OR PLEAD GUILTY TO, A CRIME OTHER THAN MISDEMEANOR TRAFFIC VIOLATIONS?
IF YES, EXPLAIN:
If your answer is “yes” to the above, you will not be automatically disqualified from employment consideration, except as required by sate or federal law.
EDUCATION / SKILLS
HIGH SCHOOL NAME
HIGH SCHOOL ADDRESS
COURSE OF STUDY
CHECK LAST YEAR COMPLETED
DID YOU GRADUATE
LIST DIPLOMA
COLLEGE NAME
COLLEGE ADDRESS
COURSE OF STUDY
CHECK LAST YEAR COMPLETED
DID YOU GRADUATE
LIST DIPLOMA
COLLEGE NAME
COLLEGE ADDRESS
COURSE OF STUDY
CHECK LAST YEAR COMPLETED
DID YOU GRADUATE
LIST DIPLOMA
OTHER EXPERIENCE, TRAINING, OR SPECIAL COURSES
AREA(S) OF SPECIALIZATION OR MAJOR INTEREST
LIST OFFICE SKILLS INCLUDING COMPUTER/SOFTWARE EXPERIENCE
WORD PROCESSING: APPROX. WPM
PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATION
TYPE
STATE ISSUED
DATE

MonthDayYear
Date
NUMBER
EXPIRATION DATE

MonthDayYear
Date
TYPE
STATE ISSUED
DATE

MonthDayYear
Date
NUMBER
EXPIRATION DATE

MonthDayYear
Date
TYPE
STATE ISSUED
DATE

MonthDayYear
Date
NUMBER
EXPIRATION DATE

MonthDayYear
Date
HAVE ANY OF YOUR LICENSES OR REGISTRATIONS EVER BEEN SUSPENDED, REVOKED OR ON PROBATION?
IF YES, PLEASE EXPLAIN.
DRIVER’S LICENSE NUMBER
STATE
EXPIRATION DATE

MonthDayYear
Date
HOW MANY YEARS HAVE YOU BEEN DRIVING?
EXPLAIN THE NATURE OF DRIVING AND TYPE OF VEHICLE(S)
MOVING VIOLATIONS (Last 3 years)
TYPE OF VIOLATION AND DATE OF VIOLATION
HAVE YOU DRIVEN EMERGENCY EQUIPMENT BEFORE?
ACCIDENTS (Last 3 Years)
NATURE OF ACCIDENT AND DATE OF VIOLATION
HAVE YOU EVER HAD YOUR LICENSE , PERMIT, OR DRIVING PRIVILEGES DENIED, SUSPENDED OR REVOKED
IF YES, PLEASE EXPLAIN:
PREVIOUS WORK EXPERIENCE

PROVIDE INFORMATION REGARDING PREVIOUS EMPLOYMENT BEGINNING WITH THE MOST RECENT EMPLOYER.
JOB TITLE
EMPLOYER
FROM: (MO/YR)
TO: (MO/YR)
SUPERVISOR’S NAME
PHONE
Format: (000) 000-0000.
ADDRESS
DUTIES
DUTIES
REASON FOR LEAVING
MAY WE CONTACT YOUR CURRENT EMPLOYER?
JOB TITLE
EMPLOYER
FROM: (MO/YR)
TO: (MO/YR)
SUPERVISOR’S NAME
PHONE
Format: (000) 000-0000.
ADDRESS
DUTIES
DUTIES
REASON FOR LEAVING
JOB TITLE
EMPLOYER
FROM: (MO/YR)
TO: (MO/YR)
SUPERVISOR’S NAME
PHONE
Format: (000) 000-0000.
ADDRESS
DUTIES
DUTIES
REASON FOR LEAVING
JOB TITLE
EMPLOYER
FROM: (MO/YR)
TO: (MO/YR)
SUPERVISOR’S NAME
PHONE
Format: (000) 000-0000.
ADDRESS
DUTIES
DUTIES
REASON FOR LEAVING
PLEASE IDENTIFY AND EXPLAIN ANY GAPS IN EMPLOYMENT LONGER THAN THREE (3) MONTHS
HAVE YOU EVER BEEN DISCHARGED FROM A JOB?
IF YES, PLEASE EXPLAIN:
BRIEFLY DESCRIBE DUTIES AND SKILLS ACQUIRED THROUGH MILITARY OR VOLUNTEER SERVICE (Include dates)
REFERENCES

LIST AT LEAST THREE (3) REFERENCES WHO ARE NOT RELATIVES:

Rows	NAME AND RELATIONSHIP	TITLE	COMPANY NAME AND ADDRESS	TELEPHONE
REF 1
REF 2
REF 3

AFFIDAVIT: I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process my disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may me required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to preceding sentence, except for a written agreement signed by an administration representative of this facility.

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
Should be Empty:

Galesburg Hospitals’ Ambulance Service

Employment Application

EDUCATION / SKILLS

PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATION

PREVIOUS WORK EXPERIENCE

REFERENCES