CAMBRIDGE AREA EMERGENCY MEDICAL SERVICES

APPLICATION FOR PAID & VOLUNTEER EMPLOYMENT

Thank you for your interest in Cambridge Area EMS (CAEMS). The information presented on this application will determine your acceptance and may also be used as a basis for your membership in the CAEMS.

You should have received a job description with this application. Please read it carefully. If you have any questions or did not receive a job description, please contact the CAEMS Director.

If you are a person with a disability and need an accommodation at any time during the recruitment, training or employment process, you are responsible for informing us and any instructors of your needs.

Please answer all questions as completely as possible. Please use the "TAB" key to move through this electronic application and then save it to your computer before submission.

TITLE OF POSITION FOR
WHICH YOU ARE APPLYING / Job Title: Choose an item.
Type of Position: Choose an item.
PERSONAL DATA
NAME: (Last, First, Middle) Click here to enter text. / DATE: Click here to enter a date.
PERMANENT ADDRESS: (Number, Street) Click here to enter text.
CITY, STATE Click here to enter text. / ZIP Click here to enter text.
HOME/CELL TELEPHONE #: Click here to enter text. / BUSINESS TELEPHONE #: Click here to enter text.
SOCIAL SECURITY #: Click here to enter text. / BIRTHDATE: Click here to enter text.
E-MAIL ADDRESS: Click here to enter text.
It is the policy of Cambridge Area EMS to check the driving record of all applicants. Please list your Wisconsin Driver’s License Number here and include a copy with this application:
Click here to enter text.

Have you ever worked as an emergency medical service worker? Choose an item.

f yes, give dates and locations: Click here to enter text.

**************************************

Highest level of education achieved (select highest grade completed): Choose an item..

AN AFFIRMATIVE ACTION EMPLOYER

FOR EQUAL EMPLOYMENT OPPORTUNITY

CURRENT CERTIFICATION / LICENSURE
License Number / Expiration Date
Emergency Vehicle Operations (EVOC): / Click here to enter text. / Click here to enter text.
CPR – Level of recognition:Click here to enter text. / Click here to enter text. / Click here to enter text.
Temporary EMT Training Permit
State: Click here to enter text. / Click here to enter text. / Click here to enter text.
Emergency Medical Responder
State: Click here to enter text. / Click here to enter text. / Click here to enter text.
Emergency Medical Technician Level of License:
State: Click here to enter text. / Click here to enter text. / Click here to enter text.
National Registry
Level: Click here to enter text. / Click here to enter text. / Click here to enter text.
Other (MD, RN, PA)
Specify: Click here to enter text. / Click here to enter text. / Click here to enter text.
WORK EXPERIENCE
Beginning with your present or mosst recent job, list your last two employers. You may also include volunteer or military experience relevant to the position for which your are applying.
Name of Company: Click here to enter text.
Address: Click here to enter text.
Your Job Title: Click here to enter text.
Supervisor's Name: Click here to enter text. / Phone No.: Click here to enter text.
Dates of
Employment: / From (Month/Year): Click here to enter text. / To (Month/Year): Click here to enter text.
Reason for Leaving: Click here to enter text.
Name of Company: Click here to enter text.
Address: Click here to enter text.
Your Job Title: Click here to enter text.
Supervisor's Name: Click here to enter text. / Phone No.: Click here to enter text.
Dates of
Employment: / From (Month/Year): Click here to enter text. / To (Month/Year): Click here to enter text.
Reason for Leaving: Click here to enter text.

Additional work experience responses may be included on a separate sheet or include a copy of your resumé.

May we obtain references from your current and previous employers and personal references? Choose an item.

If no, name and explain exceptions: Click here to enter text.

If you were discharged for cause from any employment in the last ten years, state the details: Click here to enter text.

PERSONAL REFERENCES
Do not list the same individuals who are listed under the work experience category. Please list two.
NAME (LAST, FIRST): Click here to enter text.
BUSINESS OR HOME ADDRESS: Click here to enter text.
PHONE: Click here to enter text.
NAME (LAST, FIRST): Click here to enter text.
BUSINESS OR HOME ADDRESS: Click here to enter text.
PHONE: Click here to enter text.
RECORD OF LAW ENFORCEMENT CONTACTS
Responses will not exclude you from consideration for a position. Disclosure is required prior to obtaining an Emergency Medical Technician license from the State of Wisconsin.
Have you ever been arrested, charged or convicted of any traffic violations or any violations of Municipal or City Ordinances, County Ordinances, State or Federal Law? Choose an item.
If yes, please list circumstances of arrest or law violated below (Include traffic violations. Attach separate sheets for additional information.)
Date / Municipal/County/State / Law violated / Disposition: Bail Forfeited, Fined etc.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Please add additional sheets as necessary.
ALL APPLICANTS MUST MAKE THIS CERTIFICATION
I have read the job description and in my opinion I meet the minimum requirements. I certify that all answers to the questions in this application are true, and I agree that any misstatements of material fact will cause forfeiture on my part, to any employment at Cambridge Area EMS.
SIGNATURE OF APPLICANT: / DATE:
Click here to enter text. / Click here to enter a date.

Please save a copy of this application. Identify all of your documents with your name (as filename) and submit to

Cambridge Area EMS

EMS Director

271 West Main Street

PO Box 272

Cambridge, WI 53523

Fax: 608 423-3211 Voice: 608 423-3511

Email:

Revised 3/16/2017