United Ambulance Service

Wheelchair Services Division

Job Application

Personal Information:

First Name

Middle Name

Last Name

Address

City

State

Date of Birth

Primary Phone

E-Mail

Postion Information:

Position Applying For

Location Desired

Employment Status Desired

Shifts Desired

Are You Available Weekends?

Available Start Date

If you were previously employeed by United. List dates of employment

Referral Source

Education History:

High School Name

# of Years Completed

Did You Graduate

Year Graduated

Technical/ Trade School Name

# of Years Completed

Did You Graduate

Year Graduated

Field of Study/ Degree Earned

College/ University Name

# of Years Completed

Did You Graduate

Year Graduated

Field of Study/ Degree Earned

Please Add Any Other Educational Experience

Have you taken any classes at United Training Center? If so, which class(es) and when?

Professional Certifications:

Please fill in as much of what applies to you.

Certified:

AVOC

ACLS (Medics Only)

Health Care Provider CPR

PALS

PEPP

PHTLS or BTLS

Medical Priority EMD

Expiration Date:

Instructor Status:

Yes

Employment History:

Please list your last three (3) employers starting with the most recent position. Please include military experience if applicable.

Most Recent Employer

Address

Supervisor's Name

Job Title

Job Description

Month & Year Started

Month & Year Ended

Reason For Leaving

Employer #2

Address

Supervisor's Name

Job Title

Job Description

Month & Year Started

Month & Year Ended

Reason For Leaving

Employer #3

Address

Supervisors's Name

Job Title

Job Description

Month & Year Started

Month & Year Ended

Reason For Leaving

Additional Information:

Please list any skills or special training you may have received that is not listed elsewhere on the application. (i.e. supervisory skills, electronics, computers, etc.)

Do you have any limitations which would prevent you from performing the essential functions of the job for which you are applying with or without accommodation?

If Yes, Please Explain

Have you ever been convicted of a crime?

If Yes, Please Explain

Have you ever been convicted of reckless driving, OUI, or driving to endanger?

Do you understand that due to the nature of the services we provide, an exceptional record of attendance, promptness, and dependability is required of all employees?

If You Have A Résumé, You Can Upload It Here

Upload File

Additional Information

This Application does not create a contract for employment and all positions at United Ambulance Service are employees at will.

Applicants Certification and Agreement (Please read carefully):

By checking the box below, I certify that the answers given by me to the foregoing questions and statements are correct without consequential omissions of any kind whatsoever. I do agree not to hold United Ambulance Service liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in the questionnaire. I authorize nursing homes, hospitals, companies, or person’s names as former employers to give any information regarding my employment and I hereby release said employers from all liability for any damages for issuing this information.

I Understand And Accept The Applicants Certification and Agreement As Stated Above

Thank you for your application. We have received it in the business office.