Applicant Information
First Name:
Last Name:
E-mail:
Present Address:
Home Phone:
Cell Phone / Pager:
Availability
Date Available:
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Day
Year
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50
Minutes
AM
PM
AM/PM Option
Position Applying For:
Please Select
EMT
Dispatch
Office
What type of work are you looking for?
Full Time
Part Time
Are you 18 years of Age or Older?
Yes
No
Have you ever worked for this company?
Yes
No
If yes, give dates and position:
Do you have friends or family working here?
Yes
No
Do you have a reliable means of transportation?
Yes
No
I am willing to work:
Full Time
Part Time
Overtime
Evenings
Nights
Weekends
If part time, specify hours /days:
Personal History Statement
Have you been cited for a traffic violation of any kind within the last FIVE years?
Education
High School
Name & Address
Number of Years
Please Select
1
2
3
4
Did you Graduate?
Please Select
Yes
No
Degree or Diploma?
Please Select
Yes
No
College
Name & Address
Number of Years
Please Select
1
2
3
4
Did you Graduate?
Please Select
Yes
No
Degree or Diploma?
Please Select
Yes
No
Vocational/Business School
Name & Address
Number of Years?
Please Select
1
2
3
4
Did you Graduate?
Please Select
Yes
No
Degree or Diploma?
Please Select
Yes
No
Employment History
Employer #1
Address
Type of Business
Supervisor
Reason for Leaving
Telephone Number
Dates of Employment
Starting Hourly Rate
Final Hourly Rate
Job Title
Description of Work Performed:
May we contact this Employer for a reference?
Please Select
Yes
No
Employer #2
Address
Type of Business
Supervisor
Reason for Leaving
Telephone Number
Dates of Employment
Starting Hourly Rate
Final Hourly Rate
Job Title
Description of Work Performed:
May we contact this Employer for a reference?
Please Select
Yes
No
Employer #3
Address
Type of Business
Supervisor
Reason for Leaving
Telephone Number
Dates of Employment
Starting Hourly Rate
Final Hourly Rate
Job Title
Description of Work Performed:
May we contact this Employer for a reference?
Please Select
Yes
No
Have you ever been terminated or asked to resign from any job?
Yes
No
Please explain fully any gaps in your employment history:
May we contact your current employer for a reference?
Please Select
Yes
No
EMT Applicants
Do you have a valid California State Drivers License?
Yes
No
Have you had any moving violations in the past three years?
Yes
No
Licenses and Certifications
California Emergency Medical Technician 1-A
CPR Provider
California Ambulance Drivers License
LA City Provider License
LA County Expanded Scope of Practice
I certify that all of the information that I have provided on this application is true and accurate.
Type your full name:
*
Today's Date:
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Day
Year
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50
Minutes
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AM/PM Option
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