Whitesville Ambulance Service
Personal Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Home/Work Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Basic Requirements
WVOEMS Certification
*
EMVO
EMT-B
AEMT
Paramedic
Other
Are you legally entitled to work in the United States?
*
Are you 18 years of age or older?
*
Do you possess a valid West Virginia Driver’s License and a good driving record?
*
Are there any restrictions to your WVOEMS certification or NREMT certification?
*
Do you understand that candidates will be required to pass drug urinalysis?
*
Do you understand that if hired, you will be subject to random drug testing?
*
Additional Comments
Position Desired
What position are you applying for?
Part-tine BLS
Full-Time BLS
Part-Time ALS
Full-Time ALS
Other
Skills and Experience
Please indicate if you have any of the following skills or training
*
CPR - Cardiopulmonary resuscitation
ACLS- Advanced Cardiac Life Support
PALS- Pediatric Advanced Life Support
ITLS/PHTLS- International/Pre-Hospital Trauma Life Support
Fire-Fighter 1 (not required for EMS employment)
EMS Instructor
EVOC
Other
Previous EMS Employment:
Reason for leaving previous EMS employment:
References
Please provide 3 references
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
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