Ross/West View Emergency Medical Services Authority considers all applicants for all positions, in accordance with Title VII of the Civil Rights Act of 1964, as amended, and the Americans With Disabilities Act of 1990, and the Age Discrimination if Employment Act of 1967, which prohibits discrimination in the recruitment, selection and hiring of employees.
Postiton(s) Applied for
 Today's Date will be used when the form is submitted
 		 Social Security Number
Last Name
 First Name
 Middle Name
Address Number
 Address Street
 City
 State
 Zip Code
Home Phone Work Phone Email Address
 Pager
  
Education
School Name and Location High School Undergraduate College/University Graduate
Level Completed

1234

1234

1234
Diploma/Degree Yes No Yes No Yes No
Course of Study
Primary EMS Education
EMT/Paramedic School Paramedic Cert #  
  EMT Cert #       
References
Reference 1. Name Address Phone Years Known
Reference 2. Name Address Phone Years Known
Reference 3. Name Address Phone Years Known
Paramedic Reference

Please answer the following about Medical Command
Command Facilities Years of Command  
Coordinator           Ever been removed from command? Yes  No  
  Explain if YES:  
Certifications Drivers Licence PHTLS/BTLS Other
Paramedic CPR BVR Other
EMT ACLS EVOC Other
First Responder PALS Other Other
Employment Experience
Employer

Dates Employed

 WorkPreformed
Address

Salary/Hourly at departure
Phone

 
Supervisor
Reason for Leaving
 
Employer

Dates Employed

 WorkPreformed
Address

Salary/Hourly at departure
Phone

 
Supervisor
Reason for Leaving
 
Employer

Dates Employed

 WorkPreformed
Address

Salary/Hourly at departure
Phone

 
Supervisor
Reason for Leaving
Special Skill and Qualifications- Non EMS Related
Applicant's Statement

I certify that the answers herein are true and complete to the best of my knowledge.  I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.  In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate discharge.  I understand, also I am required to abide by all rules and regulations set forth by the administration or the Board of Director’s of Ross/West View Emergency Medical Services Authority.

Electronic Statement:  This is an electronic application.  All information will be kept secure and confidential.  Upon review or at a scheduled interview you will be required to fill out a Drivers Information Form and a Criminal History Record. 

 
Signature of Applicant Date