Employment

Thank you for your interest in joining our team here at H.A.L.A.S.!

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Please take the appropriate amount of time needed to accurately fill out and provide the information below. Thank you!

The statements made herein are subject to verification to determine your qualifications for employment consideration. Thank you.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Social Security Number *

Are you eligible for employment in the United States? *

Have you ever applied with our organization in the past? *

Do you have any relatives currently employed with our organization? *

If so, please list name and relationship:

Have you ever been employed with our organization? *

If so, please list dates:

Vehicle Operator Information

PA Drivers License #: *

Expiration Date (mm/dd/yyyy): *

At any time during the past seven (7) years, have you every been denied a driver's license or been convicted of a moving vehicle traffic offense, including but not limited to, driving under the influence or reckless driving? *

If so, please explain:

Have you ever had automobile insurance cancelled or evoked or have you ever been refused automobile insurance? *

If so, please explain:

Insurance Company Name

Policy #:

Have you ever been arrested or detained by law enforcement personnel? *

Have you ever been convicted, pled guilty, or no contest to a felony or misdemeanor? *

Have you ever been finger printed for any reason? *

Have you ever been convicted of a domestic crime? *

If you answered 'Yes' to any of the questions above, please explain:

Emergency Medical Care Information

Emergency Medical Agencies Affiliated With (Present and Past)

Attach additional sheets if needed.

Please list Organization, Position, Dates, Supervisor and Contact Information

Training / Certification

Please list all training and certifications including: EMR, EMT, Paramedic, PHRN, CPR, ACLS, PALS, BTLS/ITLS,PHTLS, EVDT, Other

Medical Command Information

(Paramedics Only)

Do you currently have Medical Command Authorization?

If yes, your Medical Command Physician will be contacted for reference.

Please list Hospital, Address, Medical Command Physician and Contact Information

Has your Medical Command ever been suspended or revoked?

If yes, please list the details including dates, hospital, Medical Command Physician and reason(s) below:

Education | Military | Employment History

Please upload resume here

Please list any other professional or volunteer experience which may add to your qualifications as an employee for our organization.

Would there be any problem with us contacting your current employer for a job reference?

If yes, please explain:

Have you ever been disciplined or terminated for reckless driving?

Have you ever been placed on probation or terminated for excessive absenteeism?

Have you ever been disciplined or terminated for insubordination?

Have you ever been disciplined or terminated for violation of safety rules?

Have you ever been disciplined or terminated for assault or fighting?

Have you ever been disciplined or terminated for harassment?

Have you ever been disciplined or terminated for patient abuse?

Have you ever been disciplined or terminated for alcohol or drug related activity at work?

If yes to any of the above, please explain:

"Yes" answers will not necessarily disqualify you for employment.

References

References cannot be relatives and must have known you for a minimum for one year.

Personal References: Please list Name, Affiliation, Job Title and Contact Information

EMS References: Please list Name, Agency, Job Title and Contact Information (copy)

Health Record

Do you have any pre-existing physical conditions that may affect you in the performance of your duties as an employee of Hollidaysburg Area Legion Ambulance?

If yes, please describe:

Do you require any special accommodations to perform the essential functions of the position for which you are applying?

If yes, please list:

Terms of employment status include successful completion of a physical examination, lifting and moving test and drug test. Are you willing to undergo a physical examination, lifting and moving and drug test to prove you are physically able to perform the tasks of the job for which you have applied?

I hereby certify that the statements contained herein are true and correct to the best of my knowledge. I grant Hollidaysburg Area Legion Ambulance Service (HALAS) permission to verify such answers and investigate all references. I understand that any false statements on this application may be considered significant cause for rejection of this application or for termination if discovered subsequent to my employment status. I authorize my former employer(s) and other individuals to give information concerning me and I release them and their companies from any liability whatsoever. *

I agree

Date

NOTE: This application is void after six (6) months. If you have not been hired/contacted within that period of time and are still interested in being considered for employment status, you must reapply.

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