• Application for Employment
• First Name:*
• Middle Initial:
• Last Name:*
• Address:*
• City:*
• State:*
• Zip:*
• Email Address:
• Home Phone:
• Mobile Phone:
• Date you Can Start:*
   -Month -DayYear

  Date
• Desired Salary:
• Can you Work:*
  24 Hour ShiftsWeekendsEveningsNights
• Do you Prefer:*
  Full TimePart TimePRN (As Needed)
• Position Applying for:*
  Please Select EMT Paramedic Executive Assistant Clinical Field Supervisor Clinical Operations Supervisor Education/Instructor Maintenance Accounts Payables Accounts Receivables Human Resources CEO CCO CEDO CHRO COO
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• I am at least 18 years old and can legally work in the United States.*
  YesNo
• Explain why you answered no
• I am able to work overtime.*
  YesNo
• Explain why you answered no
• I have read the job description and understand the functions of the job I am applying for.*
  YesNo
• Explain why you answered No
• Have you applied with us before?*
  YesNo
• When
   -Month -DayYear

  Date
• Have you ever been employed by us before?*
  YesNo
• Start Date
   -Month -DayYear

  Date
• End Date
   -Month -DayYear

  Date
• Are you currently Employed?*
  YesNo
• Can we Contact your Current Employer?*
  YesNo
• Current Employer
• Current Employer Phone
• Supervisor/Manager Name
• Can you travel if the job requires it?*
  YesNo
• Explain
• Have you ever been convicted of a crime?*
  YesNo
• Explain
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• EDUCATION
• Name of High School
• City
• State
• Years Completed
• Diploma/Degree Earned
• College Attended
• City
• State
• Course of Study
• Degree Earned
• EMT Program
• City
• State
• License Number
• Date Completed
   -Month -DayYear

  Date
• Paramedic Program
• City
• State
• License Number
• Date Completed
   -Month -DayYear

  Date
• Other
• City
• State
• Certificate/License
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• EMPLOYMENT EXPERIENCE
• Current Employer
• Date Started
   -Month -DayYear

  Date
• Date Left
   -Month -DayYear

  Date
• Starting Hourly Rate/Salary
• End Hourly Rate/Salary
• Job Title
• Reason For Leaving
• Worked Performed
• Add Another Employer
  YesNo
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• EMPLOYMENT EXPERIENCE
• Employer
• Date Started
   -Month -DayYear

  Date
• Date Left
   -Month -DayYear

  Date
• Starting Hourly Rate/Salary
• End Hourly Rate/Salary
• Job Title
• Reason For Leaving
• Worked Performed
• May We Contact this Employer
  YesNo
• Supervisor/Manager
• Phone Number
• Add Another Employer
  YesNo
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• EMPLOYMENT EXPERIENCE
• Employer
• Date Started
   -Month -DayYear

  Date
• Date Left
   -Month -DayYear

  Date
• Starting Hourly Rate/Salary
• End Hourly Rate/Salary
• Job Title
• Reason For Leaving
• Work Performed
• May we contact this Employer
  YesNo
• Supervisor/Manager
• Phone Number
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• MILITARY SERVICE
• Was you in the Military*
  YesNo
• Military Branch
  Please Select Air Force Army Coast Guard Marines Navy
• Component
  ActiveNational GuardReserves
• Date of Entry
   -Month -DayYear

  Date
• Date of Discharge
   -Month -DayYear

  Date
• Rank at Time of Discharge
• Military Occupational Specialty
• Type of Discharge
• Explain If other than Honorable Discharge
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• JOB RELATED SKILLS AND CERTIFICATIONS
• Do you have a valid Missouri Class E or greater drivers license?*
  YesNo
• Do you have a valid Missouri EMT License?*
  YesNo
• Do you have a valid Missouri Paramedic License*
  YesNo
• Are you Nationally Registered for the above license?*
  YesNo
• Technology Knowledge- Rate yourself on your knowledge of the following:

  Rows	None	Fair	Good	Very Good	Excellent
  Computer Knowledge
  Accounting Software
  Microsoft Word
  Microsoft Excel
  Microsoft Outlook
  Medical Billing Software
  Electronic Patient Care Reporting Software

• Check each certification you are current in:
  ACLSACLS InstructorBTLSBTLS InstructorBLS for HealthcareBLS for Healthcare InstructorCPRCPR InstructorPALSPALS InstructorPHTLSPHTLS InstructorCritical Care
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• REFERENCES
• Name*
• Phone*
• Address
• Relationship
• Name*
• Phone*
• Address
• Relationship
• Name*
• Phone*
• Address
• Relationship
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• APPLICANT"S STATEMENT
• I certify that the information contained in this application is correct to the best of my knowledge and understand that any misrepresentation or omission of information requested on this forms is cause for denial of employment or immediate termination from South Howell County Ambulance if employed. I understand that submission of an application does not guarantee employment. I further understand that, should South Howell County Ambulance extend an offer of employmentthat such employment is “at-will” for no specified duration and may be terminated by either SouthHowell County Ambulance or myself at any time, with or without cause or notice. I agree to conform to all rules and regulations of the SHCA district to which I am applying.  I understand that if a conditional offer of employment is extended from SHCA, I may be required to submit to a fit for duty test, drug screen/alcohol test and a background screening and verification. I understand that unsatisfactory results from or refusal to cooperate with these employment tests and checks will result in withdraw of any employment offer or terminationof employment if already employed. I hereby authorize any and all schools, former employers, references, courts and any other who have information about me to provide such information to SHCA and/or its reference sourceand I release all parties involved from any and all liability for any and all damages that my result from providing such information. SOUTH HOWELL COUNTY AMBULANCE IS AN EQUAL OPPORTUNITY EMPLOYER, ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW. BY SIGNING THIS FORM BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS. 
• I have read and confirm that I understand the above statement and it is true to the best of my knowledge*
  AgreeDisagree
• By typing your name below you understand that you are signing your signature to this form.
• Printed Signature*
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• PRE-EMPLOYMENT QUESTIONAIRE
• Purpose: To help us gain a better understanding of you as an individual, your background, and your future goals. Please type or write your responses to the questions. A short paragraphwill suffice, but feel free to attach additional pages if you wish. Completing this questionnaire does not guarantee an interview or employment. It does however generate questions to ask if you’re called in for an administrative interview.
• 1.) How do you establish a working relationship with new people?*
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• 2) How do you see your studies, skills, experience and personal qualities contributing to the work of this organization?*
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• 3) Have you ever been on a team where someone was not pulling their own weight? How did you handle it?*
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• ATTACH DOCUMENTS
• If you are capable please scan and attached the following documents.
• Attach copy of Resume if applicable
  Select File

  Cancelof
• Copy of High School Diploma/GED/College Degree
  Select File

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• Copy of Valid Drivers License
  Select File

  Cancelof
• Copy of Missouri State EMT/Paramedic cards
  Select File

  Cancelof
• Copy of valid certifications list above under the CERTIFICATION Section above
  Select File

  Cancelof
• Once finished please click SUBMIT below.
• Submit
• Should be Empty: