Shippensburg Area EMS Application
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 *
First/Middle/Last Name *
Date Of Application *
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Email Address *
EMS Certification Held: *
Certification Number & Original Issue Date *
Home Address(Including City, State, Zip Code) *
Date Of Birth *
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Phone Number *
Social Security Number
Drivers License Number & State Issuing License
Undergraduate Education (Provide Name Of School, Degree and/or Certification Received & Year Completed)
Graduate Education (Please Provide Name of School, Degree and/or Certification Received, & Year Completed)
Other Education (Please Provide Name of School, Degree and/or Certification Received, & Year Completed)
Please check all EMS trainings that you currently possess (Also please have copies of your certifications to provide @ your interview)
Provide a minimum of 3 personal references. Provide all the information required on each reference. 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**
Please advise all personal references will be done through an online system; and the references email needs to be accurate, active and valid for the process to be completed.
Personal Reference 1: Name; Phone Number; How You Know Reference; Email ***Reference Must Have An Active Email For Reference Check To Be Completed *
Personal Reference 2: Name; Phone Number; How You Know Reference; Email ***Reference Must Have An Active Email For Reference Check To Be Completed *
Personal Reference 3: Name; Phone Number; How You Know Reference; Email ***Reference Must Have An Active Email For Reference Check To Be Completed *
Provide a minimum of 2 professional references. Please provide all the required information on each reference **Please note the minimum references are mandatory for the application process to continue**
Professional Reference 1: Name, Phone Number, Place of Employment; Qualification That Makes This Person A Professional Reference *
Professional Reference 2: Name, Phone Number, Place of Employment; Qualification That Makes This Person A Professional Reference *
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
Dates Employed @ Employment Experience A *
Employment Experience B
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Dates Employed @ Employment Experience B
Employment Experience C
Please Provide Employer, Employment Address, Employer Phone, Job Title, Supervisors Name, Work Duties Performed & Reason(s) for Leaving
Dates Employed @ Employment Experience C
Please list any volunteer activities you have participated in
Please list any military service assignments and/or affiliation
List any EMS organizations that you are or were previously involved with *
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)
**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
**Please note applicants may be subject to drug and alcohol screening; as well as a written and physical ability testing** *
Type your name below to acknowledge you read above statement
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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