Integhearty Ambulance Services
Application for Employment
1516 Osprey Dr. Suite 206
(972)224-7017
Personal Information Date______
Name (Last Name First) ______Social Security Number______
Present Address______Apt No._____City______State____Zip_____
Are you 18 Years or Older? Yes or No Phone Number______Cell Phone______
Are you a U.S. Citizen or authorized to work in the U.S. on an unrestricted basis? Yes No
Can you, after employment, submit: Proof of your legal right to work in the U.S.? Yes No
A birth certificate or other proof of age? Yes No
Have you ever been convicted of a crime except for a minor traffic violation, marijuana-related misdemeanor convictions occurring within the last 3 years? Have you been convicted for which the criminal record has been expunged, sealed or eradicated by the court or misdemeanor convictions for which any probation has been completed and the case dismissed by court within the last 3 years? Please include any criminal offense related to healthcare.Yes No
If yes, please give the date, location and disposition of your case:
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Desired Employment
Position______Date you can start______Salary Desired______
Indicate desired salary to be considered for employment.
Full-time Shift preferred______
Part-time Days and hours if part time______
Do you have any personal responsibilities or obligations that would restrict you from working?
early morning’s evenings overtime weekends
If yes, please explain: ______
Are you employed now? Yes or No If so may we inquire of your present employer? Yes or No
Ever applied to this company before? ______Where? ______When? ______
Who Referred You To This Company? ______
Walk In EMS School Employment Agency News Paper Friend Other
Education
School Level Name and Location of School Year Did you Subject Studied
Attended? Graduate?
Grammar School______
High School______
College______
Trade, Business
School______
General
Subjects of Special Study or Research Work______Type of License/Certification:______License/Certification#:______State: ______
Type of License/Certification:______License/Certification#:______State:______
Indicate whether there has ever been any adverse action(s) against any license(s) or certification(s) held? □ Yes □No
If yes explain:______
Special Skills______
Do you speak any foreign languages? Yes No
If so, which Languages(s)? ______
Former Employers
List Below Last Three Employers, Starting With The Most Recent.
Name of Employer______Address/City/State______
Starting Date______Leaving Date______Job Title______
Starting Salary______Final Salary/Current______May We Contact Your Boss?______
Supervisors Name/Phone Number______
Job Description______
Reason for Leaving______
Name OF Previous Employer______Address/City/State______
Starting Date______Leaving Date______Job Title______
Starting Salary______Final Salary______May We Contact Your Boss? _____
Supervisors Name/Phone Number______
Job Description______
Reason for Leaving______
Name of Previous Empoyer______Address/City/State______
Starting Date______Leaving Date______Job Title______
Starting Salary______Final Salary______May We Contact Your Boss? ____
Supervisors Name/Phone Number______
Job Description______
Reason for Leaving______
References
Name/Address/Phone Number______
______
Name/Address/Phone Number______
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Service Record
Branch of Service______
Discharge Date/Rank______
Number of years worked in applied position______
Do you believe you would be able to perform the essential functions of the job for which you are applying? Yes No
Please explain if you need accommodation______
______
As a condition of employment, you must successfully complete a post-offer, pre-employment drug and health screen and pre-employment background verification, before becoming an employee. Any job offer, as well as continued employment, is conditioned upon your being able to perform the essential functions of the job, with or without reasonable accommodation.
(I understand and agree with this provision)
______
Date Signature
Authorization
“I certify that the information contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal even if determination is made years later.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is written and signed by an authority company representative.”
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Date Signature
Office Use Only
Date of Hire______Position______Will Report______
Employment Manager______Date______
Integhearty (07/06)