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Transport (EMT) considers candidates for employment without regard to race, color, national origin, ancestry, religion, sex, age, disability, political belief, military service, or any other protected class.  \nPERSONAL INFORMATION  \nName: Today’s Date:  \nAddress: City, State Zip:  \nPhone Number: Other Phone: Date Available:  \nEmail Address:  How did you find out about this position?  If any, please list relatives or friends employed here:   \nPOSITION INFORMATION  \nApplying for job as: ☐ Carlsbad ☐ Deming ☐ Portales  \nAvailable for scheduling: ☐ Full Time ☐ Part Time ☐ Either  \nHave you been employed by Elite before? ☐ YES ☐ NO If so, when:  \nPrior position(s): Reason for leaving:  \n\n| Insert the hours and times of day you ARE NOT available to work for each day of the week: |\n| --- |\n| Sun Mon Tues Wed Thu Fri Sat |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | CERTIFICATION INFORMATION (Check all that apply-photocopies required at interview) |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  | EMS/Nursing\u003Cbr>License/Certificate |  |  | National Certificate/License |  |  | Driver’s License |  |  |  |\n| Cert/License\\#: |  |  |  |  |  |  |  |  |  |  |  |  |\n| Issued by: |  |  |  |  |  |  |  |  |  |  |  |  |\n| Exp. Date: |  |  |  |  |  |  |  |  |  |  |  |  |\n| Check each of the certificates that you currently hold. |  |  |  |  |  |  |  |  |  |  |  |  |\n| ☐ CPR |  | ☐ ACLS |  | ☐ PALS | ☐ PHTLS |  | ☐ NRP | ☐ TNCC |  | ☐ CCRN | ☐ CCEMTP |  |\n\nCan you provide proof, if hired, that you are eligible to work in the U. S.? Can you provide a list of current immunizations if employed?  \n☐ YES ☐ NO  \n☐ YES ☐ NO  \nHave you ever been excluded or are you currently excluded from participating in any federal health ☐ YES ☐ NO  \nprogram such as Medicare or Medicaid?  \nIf yes, explain:  \nEMPLOYMENT HISTORY  \n(List your last three employers or volunteer activities, starting with the most recent.)  \nEMPLOYER (1):  \n\n| Name & Address (1)\u003Cbr>Job Title:   Start Date:\u003Cbr>Job Description (including duties |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  |  | Supervisor:\u003Cbr>End Date: \u003Cbr>|  |  |\n|  | Salary:\u003Cbr>and responsibilities):  |  |  | Salary: |\n|  |  |  |  |  |\n| Employer's Telephone \\# : Reason for leaving:\u003Cbr>EMPLOYER (2): |  | May we contact? | ☐YES | ☐NO |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Name & Address (2)\u003Cbr>Job Title:   Start Date:\u003Cbr>Job Description (including duties |  |  |  |  |\n|  |  | Supervisor:\u003Cbr>End Date: |  |  |\n|  | Salary:\u003Cbr>and responsibilities):  |  |  | Salary: |\n|  |  |  |  |  |\n| Employer's Telephone \\# : Reason for leaving:\u003Cbr>EMPLOYER (3): |  | May we contact? | ☐YES | ☐NO |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Name & Address (3)\u003Cbr>Job Title:   Start Date:\u003Cbr>Job Description (including duties |  |  |  |  |\n|  |  | Supervisor:\u003Cbr>End Date: |  |  |\n|  | Salary:\u003Cbr>and responsibilities):  |  |  | Salary: |\n|  |  |  |  |  |\n\nEmployer's Telephone \\# : May we contact? ☐YES ☐NO  \nReason for leaving:  \n| Service Branch | Enlisted | Rank/Duties | Discharged |\n| --- | --- | --- | --- |\n|  |  |  |  |\n\nCOMPLIANCE HISTORY  \nAnswers of Yes for any of the above questions will not necessarily disqualify youfrom employment.  \nHave you ever been:  \n1. Disciplined or terminated for reckless driving?  \n2. Placed on probation or terminated for excessive absenteeism?  \n3. Disciplined or fired for insubordination?  \n4. Disciplined or fired for violation of safety rules?  \n5. Disciplined or fired for assault or fighting?  \n6. Disciplined or fired for harassment?  \n7. Disciplined or fired for patient abuse?  \n8. Disciplined or fired for alcohol or drug related activity at work? If you answered yes to any question above, please explain:  \nYES  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \nNO  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐","cbCaimbWGKDyyBkn","https://ap.wps.com/l/cbCaimbWGKDyyBkn","pdf",448666,"English","# Personal Information\n# Position Information\n# Certification Information\n# Employment History\n# Compliance History\n# Education and Training\n# References\n# Acknowledgment","[{\"question\":\"What personal information does the employment application request?\",\"answer\":\"The application requests the candidate’s name, address, phone number, other phone, email address, and date available, along with how they found out about the position.\"},{\"question\":\"What certification and license details must candidates check or provide?\",\"answer\":\"Candidates must check current certifications (such as CPR/ACLS/PALS and others listed) and provide information for applicable licenses/certificates, including certificate/license number, issuing authority, and expiration date.\"},{\"question\":\"How does the application handle prior employment and work history?\",\"answer\":\"Candidates must answer whether they have been employed by Elite before and provide employment history for the last three employers or volunteer activities, including job title, start/end dates, job duties, supervisor, salary, contact telephone, and reason for leaving.\"}]","Elite Medical Transport - Employment Application Form | PDF",1789306780]