	*Please fill out the appropriate sections of this Employment Application.* *Once received, the MEDIC EMS HR Manager will be in contact with you to discuss your opportunites with MEDIC EMS.*	1204 East High Street Davenport, IA 52803 Phone: (563) 323-6806
GENERAL INFORMATION

First Name:	Last Name:		MI:
Address:	City:	State:		Zip:
Email:	Phone#:	Other Phone#:
Are you legally enritled to work in the U.S.? YES NO

POSITION

Position or Type of Employment Desired:

Date Available:

Will Accept:

Part-Time Full-Time Volunteer

Shift:

Days Evening Night No Preference

EDUCATION AND TRAINING

High School Name and Location			Dates Attended Month/Year	Graduate
			From To	YES NO

College, Business School, Military (Most recent first)

Name and Location	Dates Attended Month/Year	Graduate	Credits Earned	Degree	Major or Subject
	From	Yes No	Quarterly or Semester Hours: Other:	Year:
	To
	From	Yes No	Quarterly or Semester Hours: Other:	Year:
	To
	From	Yes No	Quarterly or Semester Hours: Other:	Year:
	To
	From	Yes No	Quarterly or Semester Hours Other:	Year:
	To

Professional License(s)

Level	State/Organization	Number	Expiration Date
Critical Care Paramedic	Iowa Illinois
Paramedic	Iowa Illinois National
AEMT	Iowa Illinois National
EMT	Iowa Illinois National
EMD	IAED APCO Illinois
Driver License Class C Class D CDL Class A, B, or C	Iowa Illinois
CPR-Healthcare Provider
ACLS
PALS
PHTLS/BTLS
Occupational License, Certification or Registration	Number	Where Issued	Expiration Date



Languages Read, Written or Spoken Fluently Other Than English:

VETERAN INFORMATION (Most recent)

Branch of Service	Date of Entry	Date of Discharge

WORK EXPERIENCE (Most recent fist, include volunteer work and military experience)

Are you Presently Employed? YES NO
Employer (1)	Telephone Number (1)		From (Month/Year) (1)
Address (1)			To (Month Year) (1)
Job Title (1)	Number of Employees Supervised (1)
Specific Duties (1)			Supervisor (1)
Reason for Leaving (1)	May We Contact this Employer? (1)	Yes If Yes, Please indicate whom to contact: No

Employer (2)	Telephone Number (2)		From (Month/Year) (2)
Address (2)			To (Month Year) (2)
Job Title (2)	Number of Employees Supervised (2)
Specific Duties (2)			Supervisor (2)
Reason for Leaving (2)	May We Contact this Employer? (2)	Yes If Yes, Please indicate whom to contact: No

Employer (3)	Telephone Number (3)		From (Month/Year) (3)
Address (3)			To (Month Year) (3)
Job Title (3)	Number of Employees Supervised (3)
Specific Duties (3)			Supervisor (3)
Reason for Leaving (3)	May We Contact this Employer? (3)	Yes If Yes, Please indicate whom to contact: No

Employer (4)	Telephone Number (4)		From (Month/Year) (4)
Address (4)			To (Month Year) (4)
Job Title (4)	Number of Employees Supervised (4)
Specific Duties (4)			Supervisor (4)
Reason for Leaving (4)	May We Contact this Employer? (4)	Yes If Yes, Please indicate whom to contact: No

PERSONAL REFERENCES

Name	Title or Occupation/Employer	Relationship	Contact Phone Number

PERSONAL

Are you under 18 years of Age? YES NO
Are you a U.S. Citizen or Resident Alien? YES NO Pending Explain:
Have you ever been employed by MEDIC EMS? YES NO If Yes, dates employed:
Do you have any relatives employed at MEDIC EMS? YES NO If Yes, Name: Relationship:
By what source were you referred to MEDIC EMS for Employment?

EMERGENCY CONTACT INFORMATION

First Name:	Last Name:	Relationship:
Address:	City:	State:	Zip:
Phone#:	Other Phone#:

ADDITIONAL INFORMATION

Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, activities, accomplishments, special skills, etc. (You may exclude all information indicative of age, race, religion, color, national origin, or disability.)

A Motor vehicle Report from your Licensing State along is required for positions that have driving responsibilities. The report must be submitted with the application and be dated no more than 10 days before your application submission.

MEDIC EMS IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE IN HIRING OR EMPLOYING, IN ACCORDANCE WITH THE REQUIREMENTS OF ALL APPLICABLE STATE AND FEDERAL LAWS, ON THE BASIS OF RACE, COLOR, RELIGION, CREED, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, ANCESTRY, MARITAL STATUS, UNFAVORABLE MILITARY DISCHARGE, DISABILITY OR AGE. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION. IT IS THE POLICYOF MEDIC EMS TO PERFORM PRE-EMPLOYMENT DRUG TESTING.

IN COMPLETING THIS APPLICATION I CERTIFY ALL MY INFORMATION IS TRUST AND CORRECT AND THAT I UNDERSTAND THE QUESTIONS AND STATEMENTS CONTAINED IN THIS FORM IN THEIR ENTIRETY AND THAT MY EMPLOYMENT IS SUBJECT TO REFERENCES BEING OBTAINED AND TO SUCCESSFUL COMPLETION OF A PRE-EMPLOYMENT DRUG SCREEN, PHYSICAL ASSESSMENT, FUNCTIONAL SCREENING AND BACKGROUND CHECK. I ALSO UNDERSTAND THAT ANY MISREPRESENTATION OR OMISSION OF THE FACTS REQUESTED IN THIS APPLICATION OR ANY OTHER MEDIC EMS DOCUMENT THAT I COMPLETE MAY BE CAUSE FOR THE REJECTION OF MY APPLICATION
OR MY IMMEDIATE TERMINATION SHOULD I BE EMPLOYED BY MEDIC EMS AND I AGREE THAT MEDIC EMS MAY RELY UPON SUCH AFTERACQUIRED EVIDENCE AS A COMPLETE DEFENSE TO ANY FUTURE CLAIM ASSERTED BY ME AGAINST MEDIC EMS.

IN ADDITION, I HEREBY AUTHORIZE THE RELEASE OF ANY INFORMATION REGARDING MY SCHOOL RECORDS OR PREVIOUS EMPLOYMENT AND HEREBY RELEASE ALL PARTIES FROM ANY AND ALL LIABILITY OF DAMAGES FROM PROVIDING THE INFORMATION REQUESTED, IF EMPLOYED BY MEDIC EMS, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF MEDIC EMS, INCLUDING THE EMPLOYEE HANDBOOK AND AS AN EMPLOYEE AT WILL I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITHOUT CAUSE, AND WITHOUT PRIOR NOTICE AT ANY TIME, AT THE OPTION OF EITHER MEDIC EMS OR MYSELF. I UNDERSTAND THAT MY APPLICATION
WILL BE KEPT ON FILE FOR A PERIOD OF SIX MONTHS. AT THE END OF THAT PERIOD MY APPLICATION WILL BECOME INACTIVE. IF I WANT TO BE GIVEN FURTHER EMPLOYMENT CONSIDERATION, I WILL BE REQUIRED TO UPDATE MY APPLICATION WITH THE PERSONNEL DEPARTMENT.

Signature of Applicant
Date
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