Scribe application

Antelope Valley Emergency Medical Associates APPLICATION FOR EMPLOYMENT
Antelope Valley Emergency Medical Associates is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.
INTRODUCTORY INFORMATION:
Name*

First NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
APPLICANT QUESTIONS:
Type of work desired:*
Wage or salary desired:*
If hired, can you provide documents required to establish your eligibility to work in the U.S.?*

YesNo
Are you 18 years of age or older?*

YesNo
Can you commit to work for at least one year (12 consecutive months)?*

YesNoUnsure
Have you completed any of the following courses or degrees?*

Anatomy, collegePhysiology, collegeBachelor's degree, science majorBachelor's degree, non-science majorEMT course with certificationNone of the above
How were you referred to AVEMA (please provide referrer's name)?
Have you ever been convicted of, or pled guilty or no contest to, a crime other than a minor traffic violation?*

YesNo
If yes, please explain in detail and include the date of final disposition of the case and the nature of the offense. This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.
Education:

High School or last grade completed:
Name & Adress of School:
Course of Study:
Number of Years Completed:
Degree/Diploma:
College or Technical School:
Name & Address of School:
Course of Study:
Number of Years Completed:
Degree/Diploma:
Other Schooling or Training:
Name & Address of School:
Course of Study:
Number of Years Completed:
Degree/Diploma:
Military Experience:
Branch of Service:
From:
To:
Rank/Type of Service:
Special Training/Experience:
Record of Employment:

List positions starting with most recent:
Employer:
Telephone:
Address:
Position Title:
Supervisor:
Start Date:
Date Left:
Beginning Salary:
Ending Salary:
Duties:
Reason for Leaving:
Employer:
Telephone:
Address:
Position Title:
Supervisor:
Start Date:
Date Left:
Beginning Salary:
Ending Salary:
Duties:
Reason for Leaving:
Employer:
Telephone:
Address:
Position Title:
Supervisor:
Start Date:
Date Left:
Beginning Salary:
Ending Salary:
Duties:
Reason for Leaving:
Work-Related References: (Do not include relatives)
Reference 1
Name
Occupation
Years Known
Contact Information
Reference 2
Name
Occupation
Years Known
Contact Information
Reference 3
Name
Occupation
Years Known
Contact Information
Your Availability for Work:

We staff around the clock, so an accurate understanding of your available work hours is important. Indicate your earliest starting and latest ending times for each day. Take care entering noon (12pm) and midnight (12am). DO NOT put in vague availability such as "AFTERNOONS". Be specific as to starting and ending time. The greyed out times in each box are EXAMPLES of what we need from you.

REMEMBER that almost all of our scribes work some nights and weekends. If you say you cannot work on a particular day, please indicate the latest time you can work on the day prior so we can accurately assess your availability.
Monday
From - To
Tuesday
From - To
Wednesday
From - To
Thursday
From - To
Friday
From - To
Saturday
From - To
Sunday
From - To
Do you have any special requests or needs for a work schedule?
Please briefly explain why you would like to work in this role.
STATEMENT (Please read this statement carefully before signing this application):
I understand that employment with Antelope Valley Emergency Medical Associates (the Company) is at-will, meaning that I or the Company may terminate my employment at any time, or for any reason consistent with applicable state or federal law.
I authorize the Company to conduct a thorough background investigation of my work and personal history, and verify all data given on this application and during interviews. I hereby release the Company, and its representatives or agents, from any liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them from all liability for providing the requested information.
I understand that the Company may require the successful completion of a drug and/or alcohol test as a condition of employment.
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.
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Antelope Valley Emergency Medical Associates APPLICATION FOR EMPLOYMENT