Action Center / EMS Employment Application / Mulvane, Kansas

Personal Data

Name

Address

City

State

ZIP

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

Phone Number

Phone Number Area Code-Phone Number Prefix-Phone Number Line Number ext Phone Number Extension

Mobile Number

Mobile Number Area Code-Mobile Number Prefix-Mobile Number Line Number ext Mobile Number 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.

Please Do Not Complete The Following Field

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

Reference #1 - Phone Number Area Code-Reference #1 - Phone Number Prefix-Reference #1 - Phone Number Line Number ext Reference #1 - Phone Number Extension

Reference #2 - Name

Reference #2 - Relationship

Reference #2 - Company

Reference #2 - Phone Number

Reference #2 - Phone Number Area Code-Reference #2 - Phone Number Prefix-Reference #2 - Phone Number Line Number ext Reference #2 - Phone Number Extension

Reference #3 - Name

Reference #3 - Relationship

Reference #3 - Company

Reference #3 - Phone Number

Reference #3 - Phone Number Area Code-Reference #3 - Phone Number Prefix-Reference #3 - Phone Number Line Number ext Reference #3 - Phone Number 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

Date

MonthDay Year,

The City of Mulvane, Kansas

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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