Online Employment Application

Personal Information

Date of Application

Name   Social Security Number

Street Address    City    State   Zip       

Telephone No   E-Mail Address   Are you 18 years or older?  Yes   No  

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?  Yes   No

Employment Desired

Position Emergency Medical Technician Paramedic   Date you can start?   Hourly Wage Desired?

Are you employed now?  Yes   No     If so, may we inquires of your present employer?  Yes  No 

Referred By Callaway County Ambulance District Website Current District Employee Newspaper Advertisment Walk In Other  

Education

Name of High School Attended   Number of Years 1 2 3 4   Did you graduate?  Yes   No

Name of College Attended   Number of Years 1 2 3 4   Did you graduate?  Yes   No

Name of Other School Attended   Number of Years 1 2 3 4 Did you graduate?  Yes   No

Former Employers (List your last three employers, starting with the last one first.)

Employer   Address

Starting Date of Employment   Ending Date of Employment   Position

Salary   Reason for Leaving

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Employer   Address

Starting Date of Employment   Ending Date of Employment   Position

Salary   Reason for Leaving

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Employer   Address

Starting Date of Employment   Ending Date of Employment   Position

Salary   Reason for Leaving 

References (Give the names of three persons not related to you, whom you have known at least one year.)

Name   Address

Telephone No   Years Acquainted 1 2 3 4 5 or more

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Name   Address

Telephone No   Years Acquainted 1 2 3 4 5 or more

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Name   Address

Telephone No   Years Acquainted 1 2 3 4 5 or more

"I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.  I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.  I understand that no company representative, other than it's Board of Directors, and then only when in writing and signed by the Chairman of the Board, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."

"I have read the above statement, and I agree to be bound by the above statement"   Yes     No