JobAppForm – CARE STAR EMS

1- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Yes

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

2- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Yes

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

3- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Yes

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

PROFESSIONAL REFERENCES:

1- Full Name

Phone

Years Know & How Know

2- Full name

Phone

Years Know & How Know

PERSONAL REFERENCES: (Not relatives)

1- Full Name

Phone

Years Know & How Know

2- Full Name

Phone

Years Know & How Know

CRIMINAL HISTORY (By obtaining employment with CARESTAR EMS):

CRIMINAL History

(Initial) I will not be in violation of any probation or parole conditions

(Initial) I am not a sex offender

(Initial) I consent to allow CARESTAR EMS to conduct a criminal history check.

(Initial) I have no restrictions or injunctions preventing me from being in contact with certain individuals

ACKNOWLEDGMENT

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 not be considered for employment or for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate CARESTAR EMS in any way. Application will remain active for six month, after which time re-application will be necessary. If hired, employment will be

Are you agree to this statement?

Yes

APPLICANT'S SIGNATURE

Enter Your Name

3269 N Henry Blvd, Stockbridge, GA 30281

Call Us 470-854-8879

7 AM - 7PMMonday - Saturday

Employment Application

PERSONAL INFORMATION

Full Name

Todays' Date

Drivers Lincense Number

Address, City, State, Zip Code

Home Telephone

Cellular Phone

POSITION INFORMATION

Position Applying for

Seeking

Check the current certifications you are submitting with your application

1- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

2- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

3- EMPLOYMENT HISTORY: (List employers starting with the most recent)

Employer

Phone

May we contact

Job Title

Start Date

End Date

Job Description (including duties and responsibilities)

Supervisor

Reason for leaving

HAVE YOU EVER BEEN PLACED ON PROBATION, DISCIPLINED OR TERMINATED FOR ANY OF THE FOLLOWING: (Answer YES for any of the below questions will not necessarily disqualify you from employment)

Excessive absenteeism

Excessive tardiness

Insubordination

Violation of rules or regulations

Fighting or threats to flight

Harassment

Patient abuse

Careless or Reckless driving

Drug/alcohol related incidents

If you answered yes to any question above, please explain:

EDUCATION AND TRAINING

Did you graduate?

High School

Certification obtained

Did you graduate?

College

Certification obtained

Did you graduate?

Technical School

Certification obtained

Did you graduate?

Other School/Training

Certification obtained

Describe any other relevant qualifications, experience, or training you feel would be beneficial for us to know when considering your application

PROFESSIONAL REFERENCES:

1- Full Name

Phone

Years Know & How Know

2- Full name

Phone

Years Know & How Know

PERSONAL REFERENCES: (Not relatives)

1- Full Name

Phone

Call Us
470-854-8879

7 AM - 7PM
Monday - Saturday