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LifeCare Ambulance, Inc

An Emergency & Non-Emergency medical transportation company based in Elyria, Ohio.

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Employment Application

LifeCare Ambulance – Elyria, Ohio

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Personal Demographics
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years in Current Residence*

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Personal Demographics, Continued
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years in Previous Residence

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Preferences
Position Applying For*
Employment Desired*
- Full-Time
- Part-Time
Please summarize availability
Have you ever been employed by LifeCare Ambulance, Inc.?*
- Yes
- No
Dates of Employment
Were you referred by an employee of LifeCare Ambulance, Inc.?*
- Yes
- No
Name of Referring Employee
First Last

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Employment History 1
Current/Most Recent Employment
Position Title
Employer
City, State
City State / Province / Region
Start Date
Date Format: MM slash DD slash YYYY
Currently Employed
- Yes
- No
End Date
Date Format: MM slash DD slash YYYY
May we contact this employer for reference?
- Yes
- No
Supervisor Name
First Last
Supervisor Phone
Reason for Leaving
Please briefly describe responsibilities

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Employment History 2
Position Title
Employer
City, State
City State / Province / Region
Start Date
Date Format: MM slash DD slash YYYY
Currently Employed
- Yes
- No
End Date
Date Format: MM slash DD slash YYYY
May we contact this employer for reference?
- Yes
- No
Supervisor Name
First Last
Supervisor Phone
Reason for Leaving
Please briefly describe responsibilities

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Qualifications
Are you a certified EMS Provider?*
- Yes
- No
Please select current level of certification
Where did you obtain your EMS education?
Please list any additional credentials and/or certifications you have achieved.
Additional Education
High School Diploma/GED*
- Yes
- No
High School Location
City State / Province / Region
Do you have any college and/or technical training that you would like to add?
- Yes
- No
Please summarize additional educational achievements including degrees, licenses, certifications, and name of institution.

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Professional
Would you like to report any other professional qualities that you feel are relevant to the position for which you are applying?
- Yes
- No
Please explain
Personal
Are there any personal qualities that you would like us to know about?
- Yes
- No
Please explain
Are you 20 years of age or older?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No
(NOTE: Conviction of a felony will not necessarily disqualify you from employment.)
Please upload a copy of your resume

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References
First Reference
Name
First Last
Phone
Occupation or Relation
Second Reference
Name
First Last
Phone
Occupation or Relation

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Employment Application
LifeCare Ambulance - Elyria, Ohio
EQUAL 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?
- Yes
- No
Please 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.
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