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Application for Employment


Date of Application

Email Address
Basic Intermediate Paramedic Position Desired Status FT PT

Section A: Personal Data

Applicant's Full Name: Mr. Mrs. Miss
2 Contact Numbers Address City State Zip
1st
2nd
Are you at least 23 years of age? Current Parish of Residence
Yes No

Section B: Record of Education

Level School Name Course of Study Graduate Year and Degree
High School Y N
College Y N
Technical Y N
Other Y N

Section C: Specialized Skills

ACLS Instructor for: CPR ACLS PHTLS PALS Basic Paramedic
PHTLS Total Years of Commercial Driving Experience for Class A B C D
PALS Other:

Section D: Aditional Information

1.) Has this position been previously discussed with you by a Management Representative? Yes No

Please indicate this person's name:

2.) Please indicate schedule limitations:

3.) On what date would you be available for work?

Section E: Employment Experience

Name of Employer:
Contact Number Address City State Zip
Supervisor Job Title Dates of Employment Hourly Rate
Name of Employer:
Contact Number Address City State Zip
Supervisor Job Title Dates of Employment Hourly Rate
Name of Employer:
Contact Number Address City State Zip
Supervisor Job Title Dates of Employment Hourly Rate

Employee Check List

Please provide copies of all that apply:

  • Class D Drivers License
  • State Registry Card
  • Defensive Driving Certificates
  • PALS
  • Social Security Card
  • AHA BCLS "C" Card
  • Hazmat Certifications
  • PHTLS
  • National Registry Card
  • AHA ACLS Card
  • Board of Examiners Certificate
  • MVR

MedExpress is an Equal Opportunity Employer.
We consider applicants without regard for race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities.
I consent to take the physical examination, and such future physical examinations as may be by this institution at such times and places as the institution shall designate.
I agree to take a pre-employment drug test and will participate in future random drug screening as by this institution.

If you would like to upload your resume, please do so here:


(.pdf,.doc,.docx,.rtf) Size Limit: 20MB
 

Application Signature

Any Questions or Comments please contact the Director of Human Resources at 1-800-256-9777