Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
E-mail Address:
*
Are you 21 years or older?
*
Yes
No
Which site would you prefer to work out of?
*
Warrenton, OR
Longview, WA
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How were you referred to us?
*
Walk-In
Employee
Newspaper Ad
Facebook
Twitter
Craigslist
Other (please specify)
Others:
Position applying for
*
Have you ever applied to Medix or the Metro West family of companies before?
*
Yes
No
If yes, when?
Are you presently employed?
*
Yes
No
Date you would be available?
*
Upload Resume:
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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
*
Employer
Dates worked
Position/Description
*
Supervisor
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
*
Job 2
*
Employer
Dates worked
Position/Description
*
Supervisor
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
*
Job 3
*
Employer
Dates worked
Position/Description
*
Supervisor
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
*
References
Please list two (2) references that are familiar with your work life.
Reference 1
Name:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Years Known:
*
Reference 2
Name:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Years Known:
*
Have you ever been discharged or forced to resign from any position?
*
Yes
No
If yes, why?
Have you ever been disbarred or convicted of any offenses related to healthcare?
*
Yes
No
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?
*
Yers
No
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?
*
Yes
No
Has your driver's license ever been suspended or revoked in any state?
*
Yes
No
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 employers
Do not contact my current employer.
Do not contact any current or previous employers
Do 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.
*
Date
*
-
Month
-
Day
Year
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.
*
Date
*
-
Month
-
Day
Year
Date
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