Application Position Applied For Position Status Full-Time Part-time Position(s) EMT AEMT EMT-Intermediate Paramedic Date of Application Date Available Personal Information Last Name First Name MI Address City State Zip Date of Birth SSN (encrypted at rest) Only authorized managers can view full SSN. Driver’s License # Class Expiration State of Issue Home Phone Cell Phone Email Medical Background Hepatitis B vaccination (past 10 years)? SelectYesNo Any physical defects or diseases that might hinder duties? NoYes If yes, explain: Certification / Training Background EMT AEMT EMT-Intermediate Paramedic Certification # Expiration Current CPR? NoYes CPR Expiration Member of or affiliated with ambulance or fire company? NoYes If yes, who? Driven an ambulance or emergency vehicle? NoYes Other training / certifications Availability Availability Legal Ever convicted of a crime? NoYes If yes, explain Driver license ever suspended/revoked/lapsed for failure to renew? NoYes If yes, explain Citizen/authorized to work in the U.S.? YesNo Statements & Agreements Statement of Truth: I represent that the answers provided are true and correct for the purpose of securing employment with JEB Stuart Rescue Squad. I further understand that any misrepresentation will be grounds for refusal of this application or termination if employed. I acknowledge that I have read the VA Department of Human Resource Management’s policy concerning drug-free workplace and understand the organization may require drug/alcohol testing. I agree to the Statement of Truth Signature (type full name) Date Release of Liability for Background Check: I authorize JEB Stuart Rescue Squad to obtain and review background information (including but not limited to current/past employers, references, criminal background, driver’s license). I release the Squad and any references from liability for the same. I consent to the background check Signature (type full name) Date Submit Application
