Employment Application – Life Touch EMS

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Employment Application

Date of Application//

Personal Information

Name *

First

Last

Email *

Email

Confirm Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth//

Position Applied For:

Desired Salary

Date Available

Are you a citizen of the United States?

Yes
No

Have you ever worked for the company?

Yes
No

If yes, when did you work for Life Touch EMS?

Have you ever been convicted of a felony?

Yes
No

If you have been convicted of a felony, please explain:

EDUCATION

High School

Address

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate?

Yes
No

College

Address

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate?

Yes
No

If yes, what is your degree/certification/license?

Other

Address

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate?

Yes
No

If yes, what is your degree/license/certification?

PREVIOUS EMPLOYMENT

Company Name (1 of 3)

Please list most recent first

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Job Title

Supervisor Name

Responsibilities

Start Date//

Leave Date//

Reason for leaving

Starting Salary

Ending Salary

May we contact your previous employer for a reference?

Yes
No

Company Name (2 of 3)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Job Title

Supervisor Name

Responsibilities

Start Date//

Leave Date//

Reason for leaving

Starting Salary

Ending Salary

May we contact your previous employer for a reference?

Yes
No

Company Name (3 of 3)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Job Title

Supervisor Name

Responsibilities

Start Date//

Leave Date//

Reason for leaving

Starting Salary

Ending Salary

May we contact your previous employer for a reference?

Yes
No

REFERENCES

Please list three professional references

Full Name

Relationship

Company Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Full Name

Relationship

Company Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Full Name

Relationship

Company Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

MILITARY SERVICE

Leave blank if not applicable

Branch

From//

To//

Rank at discharge

Type of discharge

If other than honorable, please explain:

DISCLAIMER

I certify that my answers are true and correct to best of my knowledge. If this application leads to my employment, I understand that false or misleading information in my application or interview may result in my release.

Check box for acceptance of Disclaimer above

YES
NO, I understand my application will not be processed

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