Address:  City:

  Phone#:  Drivers License#:   State Issued: AL AK AZ AK CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WT

  Position Desired: Dispatcher EMT Paramedic Wheelchair

  Certifications:                     EMS Certification Level:   

  EMT Card#:              Expires:

  First Aid:YES NO                                Expires:

  CPR:YES NO                                      Expires:

  First Responder:YES NO                   Expires:

  Dispatcher Certification#:  Expires:

  Years Of Experience 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

  PLEASE TELL US ANYTHING THAT YOU FEEL IS PERTINENT.

 BY SUBMITTING THIS FORM TO ACTION AMBULANCE , YOU AGREE AND ALLOW ACTION AMBULANCE TO BEGIN PERFORMING A PRIMARY BACKGROUND CHECK ON YOU. THIS CHECK WILL BE BASED ON THE  INFORMATION YOU HAVE PROVIDED AND, WILL BE CONDUCTED IN COMPLIANCE WITH ALL APPLICABLE  FEDERAL, STATE,  AND LOCAL LAWS. ACTION AMBULANCE IS AN EQUAL OPPORTUNITY EMPLOYER. ALL EFFORTS WILL BE MADE TO KEEP EMPLOYMENT ATTEMPTS AND INFORMATION GLEANED THEREOF, CONFIDENTIAL. PRE-EMPLOYMENT DRUG SCREENS ARE PERFORMED ON ALL CANDIDATES FOR EMPLOYMENT. APPLICATIONS ARE VALID FOR THIRTY (30) DAYS FROM THE DATE OF SUBMISSION.

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