Employer:blanks* Job Title: * Start Date: * Starting Salary: * End Date: * Ending Salary: * Job Duties and Responsibilities: * Employer's Telephone Number: Area Code* Phone Number* May we contact this past employer? Yes No* Reason for leaving? *
Employer:blanks Job Title: Start Date: Starting Salary: End Date: Ending Salary: Job Duties and Responsibilities: Employer's Telephone Number: Area Code Phone Number May we contact this past employer? Yes No Reason for leaving?
Have you ever been:Disciplined or terminated for reckless driving? Yes N*o Disciplined or terminated for absenteeism? Yes No* Disciplined or terminated for insubordination? Yes No* Disciplined or terminated for safety violations? Yes No* Disciplined or terminated for workplace violence? Yes No* Disciplined or terminated for harassment? Yes No* Disciplined or terminated for patient abuse? Yes No* Disciplined or terminated for alcohol/drug use at work? Yes No*
High School: * Years Completed: Number* Did you graduate? Yes No* If not, have you received your GED? Yes No
College: Years Completed: Number Did you graduate? Yes No Degree: Major:
Technical/Other Education: Years Completed: Number Did you graduate? Yes No Degree: Major:
Name: * Occupation: * Years Known: * Telephone Number: Area Code* Phone Number*
Consumer reports may be obtained as part of the Statewide Transfer Ambulance & Rescue, Inc. evaluation of my job application/employment. The reports may be procured by the company insurance carrier, and may include my driving record, an assessment of my insurability under the company's insurance coverage, or other consumer reports. By signing this disclosure, I hereby authorize Statewide Transfer Ambulance & Rescue, Inc. to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes.
I also understand and agree that maintaining a clean driving record is essential in my job duties. Refusal by the company insurance carrier to insure me on the vehicle insurance policy may prevent my eligibilty for employment. Additionally if employed, refusal by the company insurance carrier to insure me on the vehicle insurance policy may subject me to disciplinary action up to, and including discharge.
I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate Statewide Transfer Ambulance & Rescue, Incorporated (dba STAR Ambulance) in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or STAR Ambulance is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or 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 perfor the job duties.
I understand that I may be required to undergo drug screening tests as a condition of my employment. To comply with this requirement, I consent to providing a sample of my urine or other physcial samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal 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 labratory to conduct any medical test or examination as may be required by STAR Ambulance as a condition of my employment. I hereby give my consent to the release of all information which STAR Ambulance deems necessary to determine my ability to perform job duties now or in the future.
I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from employment with STAR Ambulance.
I hereby authorize STAR Ambulance to investigate my employment history with former employers and to make any further investigation deemed necesary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release STAR Ambulance and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.
I certify that I am not now, nor have I ever been excluded from any state or federal healthcare program. I further understand that if it is determined that I was so excluded; my employment with STAR Ambulance may be terminated.