Application
Topton Community Ambulance
205 Home Road
Mertztown PA 19539
610-682-4333
chief@toptonems.net
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Email *
Name *
Address *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
PA Driver's License Number *
Social Security Number (optional)
Full-Time or Part-Time *
Preferred Shift *
Have you had any driving violations in the last 3 years? *
If yes, list dates and explain violations
Are you currently affiliated with any other EMS agency? *
If yes, provide the name of the service Medical Director
Have you ever been denied command in PA? *
If yes, please explain
Are you, or have you ever been, placed on provisional command? *
If yes, please explain
List ALL Certifications with Expiration Dates
List 3 References *
List Name, Address, Phone Number, and Years Known
Previous Employment (list most recent first) *
Education
High School Name, Degree Received, and Year
Education
College(s) Name, Degree Received, and Year
Education
EMT, Paramedic, AEMT, or PHRN Training Institute and Year Graduated
Medical History *
Required
List any other chronic medical problems
If you answered yes to any of the above medical conditions, explain how they are controlled
Please list all prescribed medications taken on a regular basis
The information provided in this application is true, correct, and complete. I understand that if employed, any misstatement or omission of fact on this application may result in my dismissal. I will also be responsible for the upkeep of any equipment issued to me during the course of my employment. I will return all equipment and uniforms if my employment is terminated. *
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