Employment - Midwest AmbuCare

First Name *

Middle Name *

Last Name *

Address 1 *

City *

State *

Zip / Post Code *

Email *

Home Phone

Cell Phone

Are you at least 21 years of age? (check if yes)

Avaialable Start Date

How did you find out about this position

Do you have any friends or relatives working here? (Check if yes)

If yes, who?

Are you willing to relocate? (Check if yes)

Have you ever worked for our organization? (Check if yes)

If yes, please include the dates and positions you worked here, as well as reason(s) for leaving

Can you provide proof, if hired, that you are eligibile to work in the U.S? (Check if yes)

Do you have a valid driver's license? (Check if yes)

Driver's license class

Issued State

Driver's license #

List all moving violations (convictions), accidents, and any suspension or revocations of your license in the last five years

Have you ever been convicted, or pled guilty or no contest to a felony or misemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended (Check if yes)

If yes, explain

Most recent employer (1)

Employer's telephone #

Job title

Supervisor's name

Start date

End date

Starting wage

Ending wage

Job description (including duties and responsbilities)

Reason for leaving

May we contact? (Check if yes)

Recent employer (2)

Employer's telephone #

Job title

Supervisor's name

Start date

End date

Starting wage

Ending wage

Job description (including duties and responsibilities)

Reason for leaving

May we contact? (Check if yes)

Recent employer (3)

Employer's telephone #

Job Title

Supervisor's name

Start date

End date

Starting wage

Ending wage

Job description (including duties and responsibilities)

Reason for leaving

May we contact? (Check if yes)

If you have military experience please include branch, dates of service, rank, and date discharged

Disciplined or terminated for reckless driving? (Check if Yes)

Placed on probation or terminated for excessive absenteeism? (Check if Yes)

Disciplined or fired for insubordination? (Check if Yes)

Disciplined or fired for violation of safety rules? (Check if Yes)

Disciplined or fired for assault or fighting? (Check if Yes)

Disciplined or fired for harassment? (Check if Yes)

Disciplined or fired for patient abuse? (Check if Yes)

Disciplined or fired for alcohol or drug related activity at work? (Check if Yes)

If you answered yes to any question above, please explain

Please list education institutes you have atteneded (High School, College) years you attended, and degrees earned

Personal Rerence (1) Please include their name, occupation, how long you have known them, and a contact phone number

Personal Rerence (2) Please include their name, occupation, how long you have known them, and a contact phone number

Personal Rerence (3) Please include their name, occupation, how long you have known them, and a contact phone number

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 hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the Company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment. If offered a position and at any time thereafter, I consent to medical examination as may be required to determine my fitness to perform the job duties. 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 job 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 discharge from this Company. I hereby authorize the Company to investigate my employment history with former employers 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, 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. By "Checking" the box you are agreeing to the statement above. *