Full Name:
Email Address:
Social Security #:
Mailing Address:
Date of Birth:
Home Telephone#:
Work Telephone#:
Spouse's Name (If married):
Children's Names and Ages (if applicable):
In case of emergency, please notify:
Current Employer:
Current Employer Address:
Current Employer Telephone:
Current Employer Position:
Current Employer supervisor:
Driver's Operator Number:
Have you been convicted of a traffic violation within the last three (3) years?:
No
Yes
Have you been ever been arrested?:
No
Yes
If yes, please explain:
Do you presently or have you ever been a member of an Ambulance Association, Fire Company
Rescue Squad or Police Dept.?:
No
Yes
If yes, please list your reasons for leaving:
Medical Courses:
EMT Certification No.:
EMT Certification Expiration Date.:
CPR Organization:
CPR Expiration:
Please list any other appropriate certifications you may have:
Would you be interested in taking the EMT course?:
No
Yes
If yes, when?:
Check any shifts you will be available to run:
12 Midnight to 6 a.m.
6 a.m. to 12 Noon
12 Noon to 6 p.m.
6 p.m. to 12 Midnight
Please enter any additional information or questions you have:
DECLARATION
By sending this application to West End Community Ambulance, I hereby affirm that all information I have given on this form is true and correct and that I understand that mesrepresentation or omission of facts, is, if I am accepted, cause for seperation. I understand that statements of employment and personal history may be thoroughly investigated and I hereby authorize such investigations and giving and receiving of information requested. I am also aware that a Criminal Records Check will be obtained by this organization. I agree that if accepted, I am subject to the Rules and Regulations of this Association.