Application for Employment and/or Membership @ Shippensburg Area EMS
Shippensburg Area Emergency Medical Services is an Equal Opportunity Employer (EOE) and provides advancement opportunities to everyone. Our Employment practices are not influenced or affected by race, color, religion, sex, national origin, age, disability, veteran’s status, or any other categories protected by law.
Type Of Application *
Date Of Application
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Email Address *
Your answer
Position Applying For *
First/Middle/Last Name *
Your answer
Home Address (Including City, State, Zip
Your answer
Best Phone Number To Reach You *
Your answer
Date Of Birth *
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Social Security Number
Your answer
Drivers License Number & State Issuing License
Your answer
Highest Grade Level Completed In High School
Undergraduate Education (Provide Name Of School, Degree and/or Certification Received & Year Completed)
Your answer
Graduate Education (Please Provide Name of School, Degree and/or Certification Received, & Year Completed)
Your answer
Other Education (Please Provide Name of School, Degree and/or Certification Received, & Year Completed)
Your answer
Please check all EMS certifications that you currently possess (Also please have copies of your certifications to provide @ your interview or official start date) *
Required
Please Provide Your Certification Number & The Original Issue Date *
Your answer
Provide a minimum of 3 personal references. Provide their name, phone number, and place of employment. Also how you know this person. Please note the person cannot be related to you & cannot be a professional reference **Please note the minimum references are mandatory for the application process to continue, and responses from the references are required for the continuation of the application process** *
Your answer
Provide a minimum of 2 professional references. Provide their name, phone number, and place of employment. Please note how this person will qualify as a professional reference for you. **Please note the minimum references are mandatory for the application process to continue *
Your answer
Employment Experience A: Start With Present Day Employer *
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Your answer
Dates Employed @ Employment Experience A
Your answer
Employment Experience B
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Your answer
Dates Employed @ Employment Experience B
Your answer
Employment Experience C
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Your answer
Dates Employed @ Employment Experience C
Your answer
Employment Experience D
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Your answer
Dates Employed @ Employment Experience D
Your answer
Please list any volunteer activities you have participated in
Your answer
Please list any military service assignments and/or affilation
Your answer
List any EMS organizations that you are or were previously involved with
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Have you ever defaulted and/or in collections for any federal aid student loans? *
Have you ever been convicted of a crime? Crime means all felonies and misdemeanors, including serious driving offenses (DWI/DUI); but does not include minor traffic offenses: *
If Yes; please give offense(s) for which convicted, date of conviction, and the jurisdiction
(Prior convection will not automatically bar an applicant from employment with in Shippensburg Area EMS; Note additional paperwork may be required at time of hire of a conviction occurred)
Your answer
**Please note we will contact you within seven business days about your application. Note: additional paperwork/clearances may need to be provided prior to interview and/or membership offer** *
Type your name below to acknowledge you read above statement
Your answer
I understand that my signature below indicates that all of the information contained in this Application and any attachments submitted to Shippensburg Area EMS is true, correct and complete to the best of my knowledge. My signature also acknowledges that any omission or false statements on the Application and/or attached statement may result in rejection of my Application or dismissal should I be employed by Shippensburg Area EMS. I hereby authorize Shippensburg Area EMS to complete a Criminal Background check and thoroughly investigate my references, work records, education and other matters related to my suitability for employment and further authorize my current and former employers to disclose to Shippensburg Area EMS any and all personnel records and such other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Shippensburg Area EMS, and any and all current and former employers, from any claims, demands or liability arising out of or in any way related to such investigation or disclosure. I consent to take a pre-employment examination and/or drug test and such future physical examinations and/or drug tests, as may be required and are consistent with business necessity, by this institution/department at such times and places as the institution/department shall designate. If my employment involves the operation of a motor vehicle, I consent to Shippensburg Area EMS requesting a copy of my motor vehicle record. I understand that nothing contained in the application or conveyed to me during any interview that may be granted is intended to create an employment contract, implied or explicit, between myself and Shippensburg Area EMS. If any employment relationship is established, I understand that I have the right to terminate my employment at any time and that Shippensburg Area EMS retains a similar right. My signature certifies that I have read and agree with the above statements and that the information in the application is true, correct and complete. *
Please Type Your Name Below To Act As A Digital Signature, Agreeing To The Above
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