Select your Application Region * Northeast Arkansas Van Buren County Arkansas Southeast Missouri St. Louis Metro Select the desired Employment Type * PERSONAL INFORMATION Email * Social Security Number * Phone * Are you 18 years of age? * How did you find out about this position? List any relatives or friends working/volunteering at Medic One? POSITION INFORMATION
Submit this form for EMT, Paramedic, or Dispatcher positions ONLY.
Select Position Applying For: EMT, Adjunct EMT Instructor, Paramedic, Dispatcher, Billing * EMT Paramedic Dispatcher Billing Adjunct EMT Instructor
Note: Dispatch positions are only available in Arkansas & St. Louis.
EMT or Paramedic License Number CERTIFICATION INFORMATION
Check all current certifications. Note: Photocopies will be required at interview.
Have you ever worked or volunteered for this organization? WORK REQUIREMENTS - GENERAL INFORMATION Can you provide proof, if hired, that you are eligible to work in the U.S.? Do you have a valid Driver’s License? Have you ever been convicted, or plead guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, or had any moving violations, or had your license revoked or suspended?
A conviction will not necessarily disqualify you from employment.
Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicaid or Medicare? EMPLOYMENT HISTORY
List your last three employers or volunteer activities, starting with the most recent.
Add First Employment History? MILITARY HISTORY Have you ever served in the Military or other branch of service? Explain any gaps in employment: PAST EMPLOYMENT Have you ever been (select all that apply):
An answer of Yes for any of the above questions will not necessarily disqualify you from employment.
EDUCATION AND TRAINING Did you attend high school? Did you attend a technical school? Do you have any other schooling or training to add? EMS/FIRE SERVICE RELATED TRAINING NOT LISTED ABOVE: EMS/FIRE/PROFESSIONAL AFFILIATIONS:
(list any affiliations not listed under prior employment)
Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know when considering your application: References
List three persons, other than relatives, who have knowledge of your work experience and/or education.
Add first professional reference? Add first personal reference? Acknowledgement *
I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for my discharge if I become a employee. I recognize that completion of this application does not mean that I will be accepted as an employee and does not obligate the Company to accept me as an employee. Applications will remain active for six months, after which time re-application will be necessary. If accepted for employment, I agree to abide by all rules, regulations and policies established by the Company and its officers and other persons in charge. I understand that, if accepted as an employee, my employment will be "at will" and either I or the Company can terminate the employment relationship at any time for any reason or no reason and without prior notice. This application is not an agreement or a contract for employment.
If offered employment and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the duties of employment.
I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by the Company as a condition of my employment and I hereby give my consent to the release of all information which the Company deems necessary to determine my ability to perform employment duties now or in the future.
I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate termination of my employment with the Company.
I hereby authorize the Company to investigate my employment history with former employers and volunteer organizations and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, elder abuse clearance check, FBI background check, and other such inquiries. I release the Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.
I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded, my employment with the Company may be terminated.
Type Your Name *