Employment Application Form

Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
E-mail Address:*
Are you 21 years or older?*

YesNo
Which site would you prefer to work out of?*

Warrenton, ORLongview, WA
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred to us?*

Walk-InEmployeeNewspaper AdFacebookTwitterCraigslistOther (please specify)
Others:
Position applying for*
Have you ever applied to Medix or the Metro West family of companies before?*

YesNo
If yes, when?
Are you presently employed?*

YesNo
Date you would be available?*
Upload Resume:

Upload a File

Cancelof
Education - High School, College, Tech School, EMT/Paramedic school. Include years attended and degree*
Job Skills & Training
List licenses and certifications that are applicable to this job, including expiration dates*
Work History - Start with most recent
Job 1*

EmployerDates worked
Position/Description*
Supervisor*

First NameLast Name
Phone Number*

Area CodePhone Number
Reason for leaving*
Job 2*

EmployerDates worked
Position/Description*
Supervisor*

First NameLast Name
Phone Number*

Area CodePhone Number
Reason for leaving*
Job 3*

EmployerDates worked
Position/Description*
Supervisor*

First NameLast Name
Phone Number*

Area CodePhone Number
Reason for leaving*
References Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Have you ever been discharged or forced to resign from any position?*

YesNo
If yes, why?
Have you ever been disbarred or convicted of any offenses related to healthcare?*

YesNo
Have you ever been excluded or made ineligible for participation in any federal or state healthcare program due to inappropriate or illegal actions or misrepresentation?*

YersNo
If you answered yes to any of the previous 2 questions, explain here.
How long have you been a licensed driver?*
Do you have any moving violations?*

YesNo
Has your driver's license ever been suspended or revoked in any state?*

YesNo
If you answered "Yes" to the above questions, please give date, place, and nature of each offense.
Employment reference checks.*

You may contact all current or past employersDo not contact my current employer.Do not contact any current or previous employersDo not contact the specific employer(s) listed below.
I certify that the preceding information is factual and complete and I understand that false information could result in dismissal from employment. *

Clear
Date*

MonthDayYear
Date
I authorize Medix Ambulance Service to conduct a criminal background check including fingerprints if necessary to meet specific federal, state, or public certifications, contracts or regulations. I understand that Medix Ambulance Service will notify me in advance of such an investigation.*

Clear
Date*

MonthDayYear
Date
Should be Empty: