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*Currently Accepting applications for Paramedic, PRN, with the possibility of Full-Time employment
APPLY ONLINE
Applicant Information
Position Applying For?
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Paramedic - Part Time Marion County
EMT - Part Time Marion County
Other - Please Specify Below
Other - Job Title Applying For?
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Name
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First
Last
Address
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City
State
Zip Code
Country
Phone Number
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Email
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Social Security Number
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Date Available
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Desired Salary
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Are you a citizen of the United States?
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Yes
No
If no are you authorized to work in the US?
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Yes
No
Do you have a current Missouri EMS License?
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Yes
No
Missouri EMS License Number / Exp Date:
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Are you Nationally Registered?
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Yes
No
Do you have a valid drivers license?
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Yes
No
Drivers License Number:
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Education
High School
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Address
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From
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To:
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Degree
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Did you Graduate?
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Yes
No
College
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Address
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From
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To
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Degree
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Did you Graduate?
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Yes
No
Other
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Address
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From
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To
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Degree
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Did you Graduate?
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Yes
No
Certifications
ACLS
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Yes
No
Expiration Date:
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PALS
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Yes
No
Expiration Date:
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ITLS / PHTLS
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Yes
No
Expiration Date:
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Haz-Mat Awareness
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Yes
No
Expiration Date:
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CPR
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Yes
No
Expiration Date:
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NIMS
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Yes
No
Expiration Date:
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Other Certification / Class:
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Expiration Date:
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Other Certification / Class:
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Expiration Date:
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Other Certification / Class:
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Expiration Date:
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Other Certification / Class:
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Expiration Date:
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EMS Backround
Have you ever driven an emergency vehicle?
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Yes
No
If yes, what type and how long?
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Has your license been suspended or revoked?
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Yes
No
Do you have Experience with ETCO2 Monitoring?
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Yes
No
Do you Have experience with 12 lead interpretation?
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Yes
No
Do you have experience with CPAP?
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Yes
No
If so, when and for what?
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List any other traffic citation including date, time, place and description.
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List the most recent traffic offense citation including date, time, place and description.
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Have you ever had judgement against you in a medical malpractice suit?
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List criminal offenses that you've been convicted of including date, place and disposition.
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Has you medical malpractice insurer ever paid a claim involving your alleged medical malpractice?
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Additional Comments:
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References
Please list three professional references.
Name
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First
Last
Relationship
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Company
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Phone Number
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Address
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Line 1
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City
State
Zip Code
Country
Name
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First
Last
Relationship
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Company
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Name
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First
Last
Relationship
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Company
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Previous Employment
Company
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Phone Number
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Job Title
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Starting Salary
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Reason for leaving
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Ending Salary
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To
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From
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Supervisor
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May we contact your previous supervisor for reference?
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Yes
No
Company
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Reason for leaving?
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Job Title
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Starting Salary
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Ending Salary
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To
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From
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Supervisor
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May we contact your previous supervisor for reference?
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Yes
No
Company
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Reason for leaving?
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Starting Salary
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Ending Salary
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Job Title
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To
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From
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Supervisor
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May we contact your previous supervisor for reference?
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Yes
No
Miscellaneous
Scholarships
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Languages ( Spoken, Written, Read, Note Fluency)
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Special Talents
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Activities / Interests
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Hobbies
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Why do you want to work for our company?
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Medical
Do you agree to take a medical exam including drug and/or alcohol screening at the districts expense evaluating the bona fide occupational qualifications of the position?
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Yes
No
Military Service
Branch
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From
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Active / Reserves
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To
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Supervisor
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Phone Number
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Rank at discharge
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Type of discharge
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If other than honorable please explain
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Disclaimer and Signature - Please read, initial where indicated, sign and date.
I hereby certified that to the best of my knowledge and belief, the answers given find me to the questions and all statements made by me in this application are correct.
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Initials Here
I hearby give permission to MCAD to contact appropriate licensing agency, and/or department of motor vehicles in any state to obtain my driving record.
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Initials Here
If employed, I agree that all material created and produced whether in writing, graphic, or broadcasting form, all inventions new or changes in process developed during my employment are the exclusive property of the company to use and/or sell and that subsequently to my employment with this company I will not disclose, use or reveal any confidential information related to the company without first obtaining written consent from an official of the company.
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Initials Here
I nearby apply for employment upon the basis and understanding that such employment may be terminated at any time upon notice given to me personally or sent to my last known address.
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Initials Here
I consent that you the employer or its agents may obtain both personal and job - related information through various means that is relevant to the consideration of this application for employment. MCAD is an “Equal Opportunity Employer” and nothing in the job posting, description, application, or potential interview process should be construed as an offer or guarantee of employment. DISCLAIMER: It is the policy of Marion County Ambulance District to prohibit discrimination on the basis of race, sex, color, national origin, religion, sexual orientation, gender identity, age, veteran status, political affiliation, genetics, or disability in the recruitment, selection and hiring of its workforce.
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Initials Here
Electronic Signature
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Please type full name as a Electronic Signature.
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