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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