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*Currently Accepting applications for EMT and Paramedic.

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Applicant Information

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Position Applying For? *

Other - Job Title Applying For? *

Name *

First

Last

Address *

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City

State

Zip Code

Country

Phone Number *

Email *

Date Available *

Desired Salary *

Are you a citizen of the United States? *

If no are you authorized to work in the US? *

Do you have a current Missouri EMS License? *

Missouri EMS License Number / Exp Date: *

Are you Nationally Registered? *

Do you have a valid drivers license? *

Drivers License Number: *

Education

High School *

Address *

From *

To: *

Degree *

Did you Graduate? *

College *

Address *

From *

To *

Degree *

Did you Graduate? *

Other *

Address *

From *

To *

Degree *

Did you Graduate? *

Certifications

ACLS *

Expiration Date: *

PALS *

Expiration Date: *

ITLS / PHTLS *

Expiration Date: *

Haz-Mat Awareness *

Expiration Date: *

CPR *

Expiration Date: *

NIMS *

Expiration Date: *

Other Certification / Class: *

Expiration Date: *

Other Certification / Class: *

Expiration Date: *

Other Certification / Class: *

Expiration Date: *

Other Certification / Class: *

Expiration Date: *

EMS Backround

Have you ever driven an emergency vehicle? *

If yes, what type and how long? *

Has your license been suspended or revoked? *

Do you have Experience with ETCO2 Monitoring? *

Do you Have experience with 12 lead interpretation? *

Do you have experience with CPAP? *

If so, when and for what? *

List any other traffic citation including date, time, place and description. *

List the most recent traffic offense citation including date, time, place and description. *

Have you ever had judgement against you in a medical malpractice suit? *

List criminal offenses that you've been convicted of including date, place and disposition. *

Has you medical malpractice insurer ever paid a claim involving your alleged medical malpractice? *

Additional Comments: *

References

Please list three professional references.

Name *

First

Last

Relationship *

Company *

Phone Number *

Address *

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City

State

Zip Code

Country

Name *

First

Last

Relationship *

Company *

Phone Number *

Address *

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City

State

Zip Code

Country

Name *

First

Last

Relationship *

Company *

Phone Number *

Address *

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City

State

Zip Code

Country

Previous Employment

Company *

Phone Number *

Job Title *

Starting Salary *

Address *

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City

State

Zip Code

Country

Reason for leaving *

Ending Salary *

To *

From *

Supervisor *

May we contact your previous supervisor for reference? *

Company *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Reason for leaving? *

Job Title *

Starting Salary *

Ending Salary *

To *

From *

Supervisor *

May we contact your previous supervisor for reference? *

Company *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Reason for leaving? *

Starting Salary *

Ending Salary *

Job Title *

To *

From *

Supervisor *

May we contact your previous supervisor for reference? *

Miscellaneous

Scholarships *

Languages ( Spoken, Written, Read, Note Fluency) *

Special Talents *

Activities / Interests *

Hobbies *

Why do you want to work for our company? *

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? *

Military Service

Branch *

From *

Active / Reserves *

To *

Supervisor *

Phone Number *

Rank at discharge *

Type of discharge *

If other than honorable please explain *

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. *

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. *

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. *

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. *

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. *

Electronic Signature *

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*Currently Accepting applications for EMT and Paramedic. APPLY ONLINE

﻿Applicant Information﻿

﻿Education﻿

Certifications

﻿EMS Backround﻿

References

Previous Employment

Miscellaneous

Medical

Military Service

Disclaimer and Signature - Please read, initial where indicated, sign and date.

*Currently Accepting applications for EMT and Paramedic.

APPLY ONLINE

Applicant Information

Education

EMS Backround