Action Center / EMS Employment Application / Mulvane, Kansas

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EMS Employment Application

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To submit an EMS Application to the City of Mulvane, please fill out the form below.

* Denotes a required field

Personal Data

Name*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Mobile Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Email*

Eligibility

Can you work legally in the United States, and, if hired, can you show proof of eligibility?*

Are you 18 years of age or older?*

Yes No

Have you ever been convicted of a crime other than a minor traffic citation?*

Yes No

If yes, provide the date and disposition. A conviction will not automatically bar you from employment.

Type of Position Desired

Shift Desired*

Day

Night

Status Preferred*

Full-time

Part-time

Education

School Name*

School Type*

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Degree Type

Degree Emphasis

Please add other schools attended below

Employment

Employer*

Phone*

Address*

Supervisor Name*

May Contact*

Yes No

Begin Date*

MonthDay Year,

End Date*

MonthDay Year,

Reason for Leaving*

Position Title*

Last Salary*

Salary Type*

Duties*

Please provide the information for any other previous employers below.

Other Training/Certifications/Skills

Certified as:

Paramedic

AEMT

EMT-I

EMT

Licenses, Certifications, and Registrations not listed previously

Other Specialized Training not listed previously

Other skills, abilities or qualifications relevant to this position, including equipment (and software) you can operate

References

Please list three professional references.

Reference #1 - Name*

Relationship*

Company*

Reference #1 - Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Reference #2 - Name*

Reference #2 - Relationship*

Reference #2 - Company*

Reference #2 - Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Reference #3 - Name*

Reference #3 - Relationship*

Reference #3 - Company*

Reference #3 - Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Signature and Declaration

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

Signature*

Please Do Not Complete The Following Field

Date*

MonthDay Year,

Online Payments Agendas & Minutes Municipal Code Forms & Applications Report A Problem

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EMS Employment Application

Personal Data

Eligibility

Type of Position Desired

Education

Employment

Other Training/Certifications/Skills

References

Signature and Declaration

Dialog Title