Employment Application LifeCare Ambulance – Elyria, Ohio Step 1 of 9 0% Personal DemographicsName* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Years in Current Residence* Personal Demographics, ContinuedPrevious Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Years in Previous Residence PreferencesPosition Applying For*-- Please Select --EMT / ParamedicEMT/ IntermediateEMT / BasicWheelchair DivisionBilling SpecialistDispatcherClinical PreceptorEMSI AssistEMSI InstructorHuman Resources ManagerAccounts Payable ClerkEmployment Desired*Full-TimePart-TimePlease summarize availabilityHave you ever been employed by LifeCare Ambulance, Inc.?*YesNoDates of EmploymentWere you referred by an employee of LifeCare Ambulance, Inc.?*YesNoName of Referring Employee First Last Employment History 1Current/Most Recent EmploymentPosition TitleEmployerCity, State City State / Province / Region Start Date Date Format: MM slash DD slash YYYY Currently EmployedYesNoEnd Date Date Format: MM slash DD slash YYYY May we contact this employer for reference?YesNoSupervisor Name First Last Supervisor PhoneReason for LeavingPlease briefly describe responsibilities Employment History 2Position TitleEmployerCity, State City State / Province / Region Start Date Date Format: MM slash DD slash YYYY Currently EmployedYesNoEnd Date Date Format: MM slash DD slash YYYY May we contact this employer for reference?YesNoSupervisor Name First Last Supervisor PhoneReason for LeavingPlease briefly describe responsibilities QualificationsAre you a certified EMS Provider?*YesNoPlease select current level of certification-- Please Select --ParamedicIntermediateEMT-BasicWhere did you obtain your EMS education?Please list any additional credentials and/or certifications you have achieved.Additional EducationHigh School Diploma/GED*YesNoHigh School Location City State / Province / Region Do you have any college and/or technical training that you would like to add?YesNoPlease summarize additional educational achievements including degrees, licenses, certifications, and name of institution. ProfessionalWould you like to report any other professional qualities that you feel are relevant to the position for which you are applying?YesNoPlease explainPersonalAre there any personal qualities that you would like us to know about?YesNoPlease explainAre you 20 years of age or older?*YesNoHave you ever been convicted of a felony?*YesNo(NOTE: Conviction of a felony will not necessarily disqualify you from employment.)Please upload a copy of your resume ReferencesFirst ReferenceName First Last PhoneOccupation or RelationSecond ReferenceName First Last PhoneOccupation or Relation Employment ApplicationLifeCare Ambulance - Elyria, OhioEQUAL OPPORTUNITY EMPLOYMENT DECLARATION LifeCare Ambulance is an equal employment opportunity employer. Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, and marital or veteran status. It is our policy to comply with all Federal, State, and local laws concerning discrimination in employment. No question in this application is intended to elicit information in violation of any such law, now will any information obtained in response to any question be used in any such violation of the law.We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications, and may assist us in possible future upgrading.CONSENT TO TERMS I understand that the information in the application will be used and that prior employers will be contacted for the purpose of investigation, as allowed or required by Federal, State, or local laws. I hereby give Lifecare Ambulance my consent to investigate all references, and to secure any other job-related information about me unless otherwise stated herein. Furthermore, I hereby release from any liability LifeCare Ambulance and its representatives for seeking such information, and all other persons, corporations, or organizations for furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.I certify that all information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered in either my application or interviews, my application may be rejected and, if I am employed, my employment may be terminated.I understand that if I am offered employment with LifeCare Ambulance that, before beginning work, I will be required to submit to a physical examination which may include an alcohol an drug screening by a physician designated and paid for by LifeCare Ambulance. I further understand that any offer of employment that I may receive will be contingent upon the results of this physical examination and screening. I also understand that any employee who refuses to undergo such a physical examination and screening will be subject to denial or discharge from employment with LifeCare Ambulance.In consideration of my employment, I agree to conform to LifeCare Ambulance rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or LifeCare Ambulance’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice at any time by LifeCare Ambulance. I understand that no LifeCare Ambulance representative, other that it’s president, and then only when in writing expressly with LifeCare Ambulance and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.Do you accept the terms and conditions noted above?YesNoPlease type your full name (this is your digital signature)*Date* Date Format: MM slash DD slash YYYY BY CLICKING THIS BOX, I UNDERSTAND THAT THIS APPLICATION IS FOR LIFECARE AMBULANCE IN LORAIN COUNTY, OH.* I understand. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.