A.R.E.A. Employement Application

Employment Application

Please complete the form below to apply for a position with us.
Full Name:*

First NameMiddle NameLast Name
Social Security Number:*
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address:*
Phone Number:*

Area CodePhone Number
Able to Start:*

MonthDayYear
Resume

Upload a File

Cancelof

Position Information
Are you at least 18 years of age?*

YesNo
Position Applying For:*
How did you hear about this position:
Type of Employment Requested:*
Do yo have Relatives or Friends working at A.R.E.A Services, Inc?*

YesNo
If Yes, please list:
Have you ever worked at A.R.E.A Services, Inc?*

YesNo
Reason or leaving:

Certification Information

Please Upload Copies

	Certification Number	Expiration Date	Issuing Agency
CPR
EMT
EMT-Paramedic
EVOC
Haz-Mat (R&I)
ACLS
PALS
BTLS
Other

Certifications:

Upload Certifications

Cancelof

Work Requirements and General Information
Can you provide proof, if hired, that you are eligible to work in the U.S.*

YesNo
Do you have a valid Drivers License?*

YesNo

Drivers License Information:*

	Class:	Issuing State:	Number:	Exp. Date:
Drivers License

List all moving violations (convictions) and accidents in the last five years:
Have you ever been excluded or are you currently excluded from participating in any federal health care plan program such as Medicare or Medicaid?*

YesNo
List any EMS Professional Affiliations (other then listed under employment)
Describe any additional qualifications or information, personal or professional, you feel would be beneficial for us to know when considering your application:

Employment History

List your last three employers or volunteer activities, starting with the most recent
Employer:*
Job Title:*
Start Date:*

MonthDayYear
End Date:*

MonthDayYear
Starting Salary:
Ending Salary:
Supervisor:*

First NameLast Name
Contact Number:*

Area CodePhone Number
Job Description:*
Reason for Leaving:

Employment History cont.

List your last three employers or volunteer activities, starting with the most recent
Employer:*
Job Title:*
Start Date:*

MonthDayYear
End Date:*

MonthDayYear
Starting Salary:
Ending Salary:
Supervisor:*

First NameLast Name
Contact Number:*

Area CodePhone Number
Job Description:*
Reason for Leaving:

Employment History cont.

List your last three employers or volunteer activities, starting with the most recent
Employer:*
Job Title:*
Start Date:*

MonthDayYear
End Date:*

MonthDayYear
Starting Salary:
Ending Salary:
Supervisor:*

First NameLast Name
Contact Number:*

Area CodePhone Number
Job Description:*
Reason for Leaving:

Military
Branch of Service:
Rank:
Location:
Date Began:

MonthDayYear
Date Discharged:

MonthDayYear

Personal References

List three separate persons, other than relatives, who have knowledge of your work experience and/or education
Name:

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Years Known:
Occupation:
Name:

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Years Known:
Occupation:
Name:

First NameLast Name
Relationship:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Years Known:
Occupation:

ACKNOLEDGMENT
I certify that the information I have given on this application is true, complete and correct. I understand that any false information or the omission of information may be considered a sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that a job opening exists and does no obligate the company in any way. Applications will remain active for six months, after which time re-applications is necessary. If hired, employment will be “at will” and either I or the employer may terminate employment witout prior notice. This application is not an agreement of a contract for employment.
If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties.
I understand that I may be required to undergo, drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employmentand again at any time requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical testing or examination as may be required by the company as a condition of employment and I hereby give my consent to release of all information which the company deems necessary to determine my ability to perform job duties now or in the future.
I further understand that refusal to submit to any alchohol or drug screen test at any time will result in immediate discharge from this company.
I hereby authorize the company to investigate my employment history with former employers and to make any further investigation necessary in connection with my application for employement, including criminal history check, driving history, child abuse clearance check, credit history and any other such inquiries. I waive all rights to see or reveid the information furnished.
I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it determined that I was so excluded, my employment with the company may be terminated.
By entering my full name below I understand that; I am digitally signing this application for employment and acknowledge that I have read and understand the above Acknoledgment.
Digital Signature:*
Date:*

Background / Reference Acknoledgment
Applicant Name:*

First NameMiddle NameLast Name
I have applied for a job with A.R.E.A. Services, Inc. as part of the application process. I understand that A.R.E.A. Services, Inc. will conduct a background and reference check which will include a review of public records, my criminal history and inquireies of my former employers and organizations of which I am a member and the references which I have provided regarding my qualifications for employment. If I am applying for a position involving the organizations finance, billing or other related activities that I also expressly agree to permit a check of my credit history.
I hereby authorize A.R.E.A. Services, Inc. to conduct a backgound and reference check as part of my application process. Further, on behalf of myself and my heirs, assignees, and personal representatives, I hereby release and forever discharge A.R.E.A. Services, Inc., its employees, agents and contractors from any and all causes of action, liability, claim, loss, costs or expenses and promise not to sue any such claims against any such person or organization, arising directly or indirectly from or attributed in any legal way to this back ground check. I also hereby release and forever discharge individual, agenies or organizations providing any information about me to A.R.E.A. Services, Inc. from any and all causes of action, liability, claim, loss, cost or expense whatsoever related to the furnishings of such information
By entering my full name below I understand that; I am digitally signing this application for employment and acknowledge that I have read and understand the above Background / Reference Acknoledgment.
Digital Signature:*
Date:*
Should be Empty:

Employment Application

Position Information

Certification Information

Work Requirements and General Information

Employment History

Employment History cont.

Employment History cont.

Employment History cont.

Military

Education and Training

Personal References

ACKNOLEDGMENT

Background / Reference Acknoledgment