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Americare Ambulance Service, Inc. Verification of Employment I understand that all statements made by me in connection with my application for employment may be checked by Americare Ambulance, and I authorize Americare Ambulance to contact my prior employers, including each of those employers listed on paragraph number one on the application form. I also authorize each such employer to answer any and all questions regarding my prior employment. I hereby indemnify Americare Ambulance and each of my prior employers listed in paragraph number one on my application and I agree to hold them harmless from any claims arising from this authorization. [I authorize Americare Ambulance to make whatever inquiries it considers appropriate concerning the information provided, including a check of my information available from credit bureaus except credit standing. I release Americare Ambulance and any person, company or institution that provides Americare Ambulance, information from any and all liability for any damages that may result from the investigation or the use or disclosure of such information.] _______________________________ _______________ _____________________________ _______________________________ Americare Ambulance Service, Inc. Employment Application NAME__________________________________DATE OF APPLICATION______________ ADDRESS___________________________________________________________________ CITY______________STATE_________ZIP CODE__________PHONE #_______________ DATE OF BIRTH___________________SOCIAL SECURITY #_______________________ REQUIRED ATTACHMENTS: (PHOTO COPIES IF APPLICABLE) _______EMT/PARAMEDIC FLORIDA STATE CERTIFICATION 1. List all jobs you have held in the last 5 years with your present or most recent job first. Include Military Service, temporary, or part-time jobs in the proper time sequence. Use an additional sheet if necessary. Date________to_______ Company Name:__________________________________________________________ Address: ________________________________________________________________ Phone #: ___________________Supervisor:____________________________________ Work Performed:__________________________________________________________ ________________________________________________________________________ Reason for Leaving: ________________________________________________________ ________________________________________________________________________ Date________to_______ Company Name:__________________________________________________________ Address: ________________________________________________________________ Phone #: ___________________Supervisor:____________________________________ Work Performed:__________________________________________________________ ________________________________________________________________________ Reason for Leaving: ________________________________________________________ ________________________________________________________________________ Date________to_______ Company Name:__________________________________________________________ Address: ________________________________________________________________ Phone #: ___________________Supervisor:____________________________________ Work Performed:__________________________________________________________ ________________________________________________________________________ Reason for Leaving: ________________________________________________________ ________________________________________________________________________ 2. Are you willing to have your present employer contacted in reference to your qualification? _______Yes _______No
_______Yes _______No
_______Yes _______No
official duties? _______Yes _______No
1._____________________________________________________________________________
8. List below three persons who are not related to you, and who would have knowledge of your qualifications for the position for which you are applying. Former co-workers, teachers, etc., do not repeat names of supervisors listed on the previous page. Name & 1._____________________________________________________________________________
9. Place of Birth:_______________________________________________________________ 10. Are you a citizen of the United States? 11. Dependents: 1.____________________________________________________________________________
12. List family members outside of your dependents to which you would
like to receive bereavement 1.____________________________________________________________________________
Date of high school graduation, or equivalent._____________________________________ Circle the number of college years completed 1 2 3 4 Name of college____________________________________________________________ Graduated _________ Date _________ Degree Course___________________________ Other schools (business, technical, correspondence, etc). Give names, address, course, date completed 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3.____________________________________________________________________________
14.Specify any language other than English, which you read, write or speak. _________________________________________________________________________________ 15. Have you ever served in a military organization? 16. Are you now, or were you ever, an active or inactive member of any
branch of the United States 17. Are you now, or were you ever, a member of the National Guard? Branch of Service _____________ Date of Service Method of separation (retirement, type of discharge) and rank at times of separation. ____________________________________________________________________________________ __________________________________________________________________________________ 18. Have you ever been convicted of an offense against the law, or are
you now under charges for any 19. Have you ever been fingerprinted other than for arrest? ____Yes____No 20. Has your license ever been revoked or suspended? ____Yes ____No 21. Have you ever been refused an operator’s license by any state? ____Yes ____No 22. Have you ever been in a motor vehicle accident in which you were at fault? ____Yes ____No ____________________________________________________________________________________ ____________________________________________________________________________________
23. List any other occupational license or certificates you may posses. ____________________________________________________________________________________ |
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(813) 930.0911 Fax (813) 936.3299 |