Miller Ambulance Service Job Application

MILLER AMBULANCE SERVICE

"Professional, Cost Effective, Medical Transport Service"
APPLICANT INFORMATION
Last Name*
First*
M.I.
Date of Birth*

MonthDayYear
Date
Email Address*
Phone*
Address*

Street Address

Apartment/Unit #

CityState

Zip Code
Date Available*

MonthDayYear
Date
Certifications held
Expirations of certification
Position Applied For*
Are you a citizen of the United States?*

YESNO
If no, are you authorized to work in the US?

YESNO
Are you certified in CPR?*

YESNO
If so, expiration?

MonthDayYear
Date
Have you ever been convicted of a felony?*

YESNO
If yes, explain
EDUCATION
High School
Address
From
To
Did you graduate?

YESNO
College
Address
From
To
Did you graduate?

YESNO
Degree
Other
Address
From
To
Did you graduate?

YESNO
Degree
REFERENCES
Please list three professional references.
Full Name*
Relationship*
Company
Phone*
Address*
Full Name*
Relationship*
Company
Phone*
Address*
Full Name*
Relationship*
Company
Phone*
Address*
PREVIOUS EMPLOYMENT
Company*
Phone*
Address*
Supervisor*
Job Title*
Starting Salary*
Ending Salary*
Responsibilities*
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Reason For Leaving*
May we contact your previous supervisor for a reference?*

YESNO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason For Leaving
May we contact your previous supervisor for a reference?

YESNO
MILITARY SERVICE
Branch
From

MonthDayYear
Date
To

MonthDayYear
Date
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Please verify that you are human*
Should be Empty:

MILLER AMBULANCE SERVICE

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE