Employment & Volunteer Application

CLL Application Form

Date of Application

AN EQUAL OPPORTUNITY EMPLOYER

Federal law obligates Centre LifeLink EMS to provide reasonable accommodation to the known disabilities of applicants and employees, unless to do so would pose an undue hardship. Please feel free to let us know if you need any accommodations to complete the application process or to perform any essential elements of the position sought.

Applicants are considered for all positions, and staff members are treated during their time of service, without regard to race, color, religion, sex, national origin, ancestry, marital status, age, disability, veteran status or any other prohibited basis of discrimination, as provided under applicable state and federal law.

Paid Position Applying for:

EMT Full-Time

EMT Part-Time (on call)

EMT-P Full-Time

EMT-P Part-Time

Volunteer Position Applying for:

Non-emergency Van

Administrative

EMT

Search and Rescue

Contact Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Are you 18 years or older?

Yes

Certifications

CPR

Expiration Date

EMT / Paramedic / PHRN

Expiration Date

EVOC

Expiration Date

Haz Mat

Expiration Date

ACLS / PALS* ALS Provider

Expiration Date

ICS 100 / ICS 700

Expiration Date

Do you have the right to work in the United States?

Yes

Have you been convicted of a felony with in the last 10 years? (A conviction is not an automatic bar to employment. Each case will be considered on its own merits)

Yes

If yes, please explain:

Have you ever been convicted of any crime relating to the use, sale, possession or transportation of narcotics, habit forming or dangerous drugs?

Yes

If yes, please explain:

Do you currently use illegal drugs?

Yes

If yes, please explain:

Have you been convicted of theft within the last 10 years?

Yes

If yes, please explain:

Have you ever applied for a position with or worked for Centre LifeLink EMS, Inc. before?

Yes

If yes, specify dates/information:

Education

High School

College

Other

Employment

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate, for example, race, color, religion, sex, disability or national origin.

Company Name

Address Line 1

Address Line 2

City

State

Zip Code

Name of Supervisor

Job Title

Describe Your Work

Reason for Leaving

Employment #2

Company Name

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Describe Your Work

Reason for Leaving

Employment #3

Company Name

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Describe Your Work

Reason for Leaving

Background

To assist us to check records and to verify prior employment and education, please indicate whether you were ever employed or enrolled under a name other than that used on this application:

Yes

If yes, please specify name:

If you are employed now, may we contact your current employer?

Yes

Do you have a valid Driver’s License?

Yes

Driver's License Number

State

Have you ever had your driver’s license suspended or revoked?

Yes

If yes, please explain:

Do you authorize a Driver’s License Check?

Yes

List any and all traffic citations received and accidents you have been involved in during the last five years:

References

List the names and addresses, and telephone numbers of at least three references who are not related to you:

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

I certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any of the statements verified by Centre LifeLink EMS unless I have indicated to the contrary. I authorize the references listed, as well as previous employers, to provide Centre LifeLink EMS any and all information concerning my previous employment and any other pertinent information that they may have. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer of employment, ability to volunteer or, if I am hired, my dismissal from employment.

I understand that this application is not a contract of employment.

I agree to conform to the rules and standards of Centre LifeLink EMS, as amended by Centre LifeLink EMS from time to time at its discretion. I further agree that I can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of Centre LifeLink EMS.

E-mail any attachments to: bmcminn@centrelifelink.com

Brandon McMinn, NRP Paramedic, Deputy Chief, Training Supervisor

Signature ( Name )

Date