Campion Ambulance Service, Inc.
Online Application for Employment
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Best Time to Calll
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Mobile Phone Number (if different)
-
Area Code
Phone Number
What position are you applying for?
*
(ex. Livery Driver, EMT, Paramedic, Dispatcher, etc.)
Have you submitted an application to Campion before?
*
No
Yes
Have you been employeed by Campion before?
*
No
Yes
Previous Employment Start Date
-
Month
-
Day
Year
Date
Previous Employment End Date
-
Month
-
Day
Year
Date
Are you legally eligible for employment in this country?
*
Yes
Is this application a request for re-employment following an extended military leave of absence from the company?
*
Not Applicable
Yes
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Type of work desired?
*
Part-Time
Full-Time
Will you work overtime if required?
*
No
Yes
If No, please explain:
Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?
*
Yes
No
ThIS question is not designed to elicit information about any disability. Such issues, including whether or not accomodations are needed, may be addressed at a later stage, to the extent permitted by law.
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Driver's License Number
*
State Issued
*
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-Dist. of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IA-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
PR-Puerto Rico
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
VI-Virgin Islands
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
International
Have you ever been bonded?
No
Yes
Have you ever entered into an agreement with any former employer or any other party (such as a non-competitive agreement), that might, in any way, restrict your ability to work for our company?
No
Yes
If Yes, please explain:
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Employment History
If you wish, you can upload a copy of your CV and/or resume at the end of this section
Previous Employer 1
Company
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Job Title
Immediate Supervisor
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What did you like least about your position?
Why did you leave?
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Previous Employer 2
Company
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Job Title
Immediate Supervisor
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What did you like least about your position?
Why did you leave?
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Previous Employer 3
Company
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Job Title
Immediate Supervisor
Summarize the type of work performed and job responsibilities
What did you like least about your position?
What did you like most about your position?
Why did you leave?
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
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Other Information
You can upload your Resume, CV or other supporting documentation at the end of this page.
Explain any gaps in your employment other than those due to personal illness, injury or disability.
Have you ever been fired or asked to resign from a previous job?
No
Yes
Please explain:
Attach Files
Browse Files
File types: pdf, doc, docx, txt
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Education
Starting with your most recent school attended, provide following information. (If you have provided this information on an uploaded CV/Resume, you can skip this section)
School 1
School (include City and State)
Years Completed
Completed
Diploma
GED
Degree
Certification
Other
Major/Minor
GPA/Class Rank
School 2
School (include City and State)
Years Completed
Completed
Diploma
GED
Degree
Certification
Other
Major/Minor
GPA/Class Rank
School 3
School (include City and State)
Years Completed
Completed
Diploma
GED
Degree
Certification
Other
Major/Minor
GPA/Class Rank
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References
Reference 1
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to you
Years Known
Reference 2
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to you
Years Known
Reference 3
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to you
Years Known
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Related Information
List special accomplishments, awards, publications, etc.
Is there any other job-related information you want us to know about you?
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Complete Your Application
Your Signature
*
I certify that all information I haw provided in order to apply for and secure work with this Campion Ambulance Service, Inc., is true, complete and correct.
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