PLEASE READ BEFORE FILLING OUT THIS APPLICATION
Thank you for considering employment with Mid Georgia Ambulance Service. To assist us in assessing employment opportunities for you, we are asking that you fill out this application in detail, taking time to complete the application fully, so your background can be properly evaluated in comparison to job requirements. The information you provide on this application will be treated confidentially. Incomplete information may delay or prevent employment consideration. If the spaces on this application form do not provide sufficient space for a complete explanation of any subject, write the additional information on a plain sheet of paper and fax to 478-742-0358.

Mid Georgia Ambulance is an equal opportunity employer. It is the policy of this compay to make employment selections on the basis of job related knowledge, skill, ability, and proper evidence of qualification. Recruitment, employment, and treatment of employees are practiced without discrimination because of race, color, sex, religion, age, national origin, or disability.

Should you need assistance in completing this application, we will be glad to help you in any way possible. Your application will remain under active consideration for six (6) months from the date you apply. If you still wish to be considered for employment after that date a new application must be completed.

PERSONAL DATA

Social Security Number:
To be requested at a later date.		 Telephone Numbers:
Home:  
Work:  		 Date of Application:
Last Name:
 First Name:
 Middle Name:
Address:
 County:
City:
 State:
 Zip:
Job applied for:
 Salary Desired:
 Date you can start:
Are you 18 years or older?
Yes    No		 If under 18 years of age, please give date of birth and provide proof of your eligibility to work.
Have you applied here before?
Yes    No		 If yes, when?
 Driver's License Number
Are you willing to relocate?
 Are you currently employed?
 How did you hear about us?
Have you ever been employed with us before?
Yes    No		 Dates of Employment:
From:     To: 
Are you a U.S. Citizen?
Yes    No		 Can you, after employment, submit verification of your legal right to work in the United States?
Yes    No
Have you ever been convicted of a felony?
Yes    No		 If yes, explain:
Do you want full-time or part-time?
Full-time    Part-time		 Are you willing to work any shift?
Yes    No		 Do you want a specific shift?
Yes    No

Military Service

Branch:
 Entry Date:
 Discharge Date:
Last Rank:
 Major Duties:
Specialized Training:

EMPLOYMENT HISTORY

Please begin with present or most recent employer, also list summer and temporary employment. Account for all periods of employment and unemployment for the last five employers or the last ten years, whichever covers the longest period of time.

Employer:
 Address:
Phone:
 Job Title:
 Supervisor Name & Title:
Annual Salary or Hourly Rate:
 Dates Worked:
From:    To:
Work Performed:
Reason for Leaving:

Employer:
 Address:
Phone:
 Job Title:
 Supervisor Name & Title:
Annual Salary or Hourly Rate:
 Dates Worked:
From:    To:
Work Performed:
Reason for Leaving:

Employer:
 Address:
Phone:
 Job Title:
 Supervisor Name & Title:
Annual Salary or Hourly Rate:
 Dates Worked:
From:    To:
Work Performed:
Reason for Leaving:

Employer:
 Address:
Phone:
 Job Title:
 Supervisor Name & Title:
Annual Salary or Hourly Rate:
 Dates Worked:
From:    To:
Work Performed:
Reason for Leaving:

Employer:
 Address:
Phone:
 Job Title:
 Supervisor Name & Title:
Annual Salary or Hourly Rate:
 Dates Worked:
From:    To:
Work Performed:
Reason for Leaving:


May we check with your current employer for a reference?
Yes    No
Have you ever been terminated or asked to resign from a job, or know of any reason why you might receive an unfavorable reference?
Yes    No
If yes, explain:

Special Skills/Certifications

List any business machines or equipment you are experienced in operating:
 Typing Speed, WPM:
Certifications (Identify skill level):
 Certification Number:
State of Certification:
 Expiration Date:
 Are you an instructor?
Certifications and Expiration Dates:
ACLS      BCLS      BTLS      CPR      PALS      PHTLS 
List any other special job related skills and qualifications you have which you feel would qualify you for a position with this company.

EDUCATION

High School:
 City, State:
 Major/Minor Subjects:
 Last Year Comp.:
 Diploma/Degree:
College/University:
 City, State:
 Major/Minor Subjects:
 Last Year Comp.:
 Diploma/Degree:
College/University:
 City, State:
 Major/Minor Subjects:
 Last Year Comp.:
 Diploma/Degree:
Business/Technical:
 City, State:
 Major/Minor Subjects:
 Last Year Comp.:
 Diploma/Degree:
Other:
 City, State:
 Major/Minor Subjects:
 Last Year Comp.:
 Diploma/Degree:
Describe other education or specialized training:
Scholastic honors (honor societies, prizes, scholarships, etc.)

REFERENCES

Name
 Occupation
 Years Known
Address
 Phone

Name
 Occupation
 Years Known
Address
 Phone

Name
 Occupation
 Years Known
Address
 Phone

APPLICANT'S STATEMENT

FOR SAFETY, HEALTH, AND WELL BEING OF MID GEORGIA AMBULANCE SERVICE EMPLOYEES, A DRUG & ALCOHOL POLICY IS IN EFFECT AT THIS COMPANY, MID GEORGIA AMBULANCE SERVICE IS COMMITTED TO A DRUG & ALCOHOL FREE WORKPLACE.

Realizing that this company has the right to employ persons who will provide high standards of service, I understand that:

As part of the normal employment application process the company may verify information on this application including inquiries about my current and former employment, character, general reputation, and personal characteristics through interviews with current and former employees, business associates, or other individuals or agencies. If I am employed and drive a company vehicle or a vehicle on behalf of the company, the company will periodically inquire about my driving record.

An offer of employment is contingent upon satisfactory references, verification of information on this application, the availability of a job for which you are qualified, and my ability to comply with applicable regulations issued by the Immigration and Naturalization Service. I agree to submit to drug and alcohol testing with the limits prescribed under federal, state, and local law. Employment with Mid Georgia Ambulance Service will require a successful completion of the pre-employment drug and alcohol testing.

Filing this application in no way assures me a position with this company, and if I am hired, makes no guarantee regarding my future with this company.

This application is not a contract of employment and my employment and compensation may be terminated with or without cause at any time by either the company or myself and no company representative has the authority to enter into any employment agreement with me contrary to the foregoing.

By clicking submit below, I certify this information is factual and complete. I understand that any falsification, misrepresentation or omission, either in this application or in connection with any background investigation, will be grounds for invalidation of this application or termination of employment. I further certify that my signature below indicated that I have read and understand the above statements and provisions and agree to all statements and provisions above.

Date: Email Address: