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Audrain Ambulance District
Application for Employment
Personal Information
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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When can you start? (mm/dd/yyyy)
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Salary Requirement
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Have you previously been employed with us?
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Yes
No
Position applying for:
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EMT
Paramedic
Other
Employment Status Desired:
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Full-time
Part-time
Education
High School
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Did you graduate or receive a GED?
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Yes
No
College/Tech School/Other
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Did you graduate?
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Yes
No
Still working on it
Course of study:
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Licenses/Certification
Please list any specialty license or certifications you have.
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Previous Employment
1. Employer
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Phone Number
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Job Title
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May we contact them?
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Yes
No
Date of Employment:
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Reason for Leaving
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2. Employer
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Phone Number
*
Job Title
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May we contact them?
*
Yes
No
Date of Employment:
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Reason for Leaving
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3. Employer
*
Job Title
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Phone Number
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May we contact them?
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Yes
No
Date of Employment:
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Reason for Leaving
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Has your personal license or certification ever been suspended or revoked?
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Yes
No
Have you ever pled guilty to, been convicted of, or pled "no contest" to a felony or a misdemeanor charge regardless of the sentence imposed?
*
Yes
No
If yes, please explain:
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Have you ever been required to register as a sex offender according to the laws of the state of Missouri or any other state?
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Yes
No
If yes, please explain:
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References
1. Name
*
Phone Number
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2. Name
*
Phone Number
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3. Name
*
Phone Number
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Upload Resume
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Max file size: 20MB
The responses given above are true and correct. I have not withheld any fact which might adversely affect my application, and I understand any omissions of fact or any false or misleading statements will be considered just cause for immediate dismissal, no matter when discovered. I further understand there may be no positions currently available. I agree all former employers, or any other persons, may furnish the Audrain Ambulance District with all information regarding my character and qualifications. I release all such employers and persons from any liability regarding the provision or use of such information. I understand if I am offered employment, I am not required to furnish any information which is prohibited by federal, state, or local law, and I may request reasonable accommodations, if needed due to disability in order to participate in the overall application process. I will be required to successfully complete a job related health screening, including blood and urine drug testing, provided and paid for by the Audrain Ambulance District. I also relinquish any claims and ownership of any specimen provided to Audrian Ambulance District. I will provide such documents as required by "The Immigration Reform and Control Act of 1986." I understand my employment application, including past references, a reference from my present supervisor, including disciplinary actions, if any, and attendance records may be made available to the Audrain Ambulance District to which I have applied.
We appreciate your interest in the Audrain Ambulance District. It is the policy of the Audrain Ambulance District not to discriminate in regard to employment on the basis of race, age, religion, gender, color, national origin, ancestry, or medical conditions unrelated to the ability to perform essential functions of the job.
Audrain Ambulance District does not offer tenured or guaranteed employment, either Audrain Ambulance District or the employee can terminate the employment relationship at any time, with or without cause, with or without notice.
Do you agree to the above statement?
*
Yes
No
Submit
Home
Make A Payment
About Us
Audrain Ambulance Blog
Board Information
Staff
Helpful Resources
Emergency Preparedness
HIPPA Compliance Information
About Your Privacy
>
Medical Privacy
Website Privacy
Health Information
>
FAQ | Helpful Hints
What to do after calling 911
Billing Department
Calendar
Training
Contact Us