313 Bridge Street     Beaver, PA 15009         724-728-3621

PERSONAL

Last Name:
First Name:
Middle Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Social Security #:
Driver's Licencse (State & Number):
Have you ever previously applied for employment with this company?
	Choose Here YES NO
Are you 18 years of age or older?
	Choose Here YES NO

If hired, you must provide written evidence that you are authorized to work in the United States.

Have you ever been convicted of a felony or misdemeanor?
	Choose Here YES NO If yes, please provide:
Nature of Conviction(s):
Date of Conviction(s):
Jurisdiction(s):
Sentence(s) Imposed:
Types of Rehabilitation, if any:
Have you ever been discharged from a position for making threats, fighting or any incidents involving violence?
	Choose Here YES NO
Is there any additional information we need about your name to verify your employment record?
	Choose Here YES NO
If yes, please specify.

EMPLOYMENT DESIRED

Position Applying For:
Date available to start work:
Type of employment desired
	Choose Here Full-time Part-time Full and Part-time
Are you able to work shifts?
	Choose Here YES NO

EDUCATION

Do you have a high school diploma or equivalent?
	Choose Here YES NO
Do you have a college degree?
	Choose Here YES NO
If yes, type and what field?:
If applying for an EMS position, do you have EMS Certification(s)?
	Choose Here YES NO
If yes, provide certification#(s) and expiration date(s)?:

Additional training/skills, experience, special achievements, certificates, etc. relevant to the desired position:

EMPLOYMENT
Please give accurate, complete full-time and part-time employment information. Start with your present or most recent employer.

Company Name:
Address:
Supervisor:
Job Title:
Description of Duties:
Telephone Number:
Employeed From (Month and Year):
Employeed To (Month and Year):
Weekly Pay - Starting:
Weekly Pay - Ending:
Reason for Leaving:

Company Name:
Address:
Supervisor:
Job Title:
Description of Duties:
Telephone Number:
Employeed From (Month and Year):
Employeed To (Month and Year):
Weekly Pay - Starting:
Weekly Pay - Ending:
Reason for Leaving:

Company Name:
Address:
Supervisor:
Job Title:
Description of Duties:
Telephone Number:
Employeed From (Month and Year):
Employeed To (Month and Year):
Weekly Pay - Starting:
Weekly Pay - Ending:
Reason for Leaving:

U.S. MILITARY SERVICE

Did you serve in the U.S. Armed Forces?
	Choose Here YES NO If yes, please provide:
Which Branch:
Service Start Date:
Service End Date:
Highest Rank Achieved:
Speciality:
Training/experience relevant to desired position:

REFERENCES (Do not include relatives)

Name:
Occupation:
Years Known:
Address:
Phone Number:

Name:
Occupation:
Years Known:
Address:
Phone Number:

Name:
Occupation:
Years Known:
Address:
Phone Number:

I verify that all of the statements herein are true and correct and I further understand that any falsification or willful omission shall be sufficient cause for denial of employment or dismissal.

Signature _____________________________________________ Date __________________

APPLICANT'S STATEMENT

I understand that Medic Rescue follows and "employment at will" policy, in that Medic Rescue or I may terminate my employment at any time, or for any reason consistent with applicable state and federal law. I understand that this "employment at will" policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the chief operating officer of Medic Rescue. I understand that this application is not a contract of employment. I understand that federal law prohibits the employment of unauthorized aliens. I understand that if I am offered employment that I must submit satisfactory proof of employment authorization and identity and that the failure to submit such proof will result in denial of employment.

I understand that this application will be active for a period of ninety (90) days. After that time, if I wish to be considered for employment, I must submit a new Application for Employment.

I understand that Medic Rescue will thoroughly investigate my work and personal history and verify all data given on this application, on related paper and in interviews. I authorize all individuals, schools and companies named therein, except my current employer, if so noted, to provide any information requested about me and unconditionally release and hold harmless any named or unnamed individual, school or company from any and all liability resulting from furnishing information about me.

I have read and understand all of the above and agree to the above-noted policies of Medic Rescue.

Signature _____________________________________________ Date ________________

I further understand that Medic Rescue has a drug and alcohol policy that provides for pre-employment testing and that Medic Rescue strongly believes in its responsibility to provide a safe workplace for all its employees. I understand that at any time after I am hired, Medic Rescue may require me to submit to a physical examinatin to the extent permitted by law. I consent to the disclosure of the results of the physical examinations and related tests to Medic Rescue. I understand that I may be tested for the presence of controlled substances before I am hired as a condition of employment with Medic Rescue. I also understand that an offer of employment may be made contingent on passing a job-related physical examination. I agree to submit to controlled substances screening and physical examination by Medic Rescue's designated physician and/or other medical practitioner.

I have read and understand all of the above and agree to the above-noted policies of Medic Rescue.

Signature _____________________________________________ Date ________________

I also understand that Medic Rescue has a policy requiring all applicants to submit a state and/or federal Child Abuse History and Criminal History Record Information report form. I also understand that I may be required to submit a set of fingerprints to the state police and that the state may charge a $10.00 fee to conduct the criminal history record check. I further understand that I may be required to pay the fee to the Commonwealth of Pennsylvania and/or fees required for the federal criminal history record check.

I have read and understand all of the above and agree to the above-noted policies of Medic Rescue.

Signature _____________________________________________ Date ________________

Medic Rescue is an equal opportunity employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, physical or mental disability or any other status protected by applicable law.