United Ambulance Service

Wheelchair Services Division

Job Application

Personal Information:

First Name

Middle Name

Last Name

Address

City

State

Primary Phone

E-Mail

Postion Information:

Available Start Date

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

Education History:

High School Name

# of Years Completed

Technical/Trade School Name

# of Years Completed

Field of Study/Degree Earned

College/University Name

# of Years Completed

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.)

If You Have A Résumé, You Can Upload It Here

Upload File

Referred By / 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.