Position Desired: EMT-Basic EMT-Advanced Paramedic Medical Transportation Other     Hours Requested: Full-Time Part-Time PRN (As Needed) Seasonal Any

Last Name:   First:   Middle Initial:

Address:

City:   State:   Zip:

Phone:     Email Address:

If certified by the Indiana EMS Commission, what level of certification do you hold? N/A EMT-Basic EMT-Basic Advanced EMT-Intermediate EMT-Paramedic     PSID Number:

Are you at least 18 years of age? Yes No    

Date available to start:                    

How did you find out about this position?

Do you have any friends or relatives working here? Yes No
If yes, please list:

Have you worked here before?                     Yes No     If yes, when?

        Prior position here:     N/A EMT Paramedic Driver Clerical Other
        Reason for leaving:   

Do you have a valid Drivers License? Yes No     Type: N/A Operators Public Passenger CDL
                                                                                State:
Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, or had your license revoked or suspended? Yes No

Please list all moving violations (convictions) and accidents and any suspensions or revocations of your drivers license in the last five years (a conviction will not necessarily disqualify you from employment):

Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid? Yes No

If you answered 'Yes' to the above question, please explain:

Anything else you would like us to know about you:

By submitting this application you are attesting that the information contained in it is true, correct and complete to the best of your knowledge. False statements made in this application will disqualify you for employment or be grounds for termination if discovered after you are hired.