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Employment Application
First Name
Last Name
Email
Phone Number
Address
Date of Birth
Position
EMT-B
EMT-IV
Paramedic
Dispatch
Availability
Full Time
Part Time
PRN Flex
Days Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday Saturday
Time Available
Day Shift
Night Shift
24 Hour Shift
Have you ever been convicted of a crime, including misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by court?
Yes
No
If yes, please explain:
What can I contribute to the Mountain States Team?
What does Customer Service mean to you?
How can you ensure you always represent the company in a good manner?
What can Mountain States do to ensure you are proud and happy to be part of the team?
List all employers, starting with the most recent. All information must be completed
Employer 1
Employer Name
May we contact this employer
Yes
No
Is this your current employer?
Yes
No
Title
Dates of employment
to
Salary per Hour
Supervisor Name
Employer Contact Number
Employer Contact Email
Description
Reason for Leaving
Employer 2
Employer Name
May we contact this employer?
Yes
No
Is this your current employer?
Yes
No
Title
Dates of employment
to
Salary per Hour
Supervisor Name
Employer Contact Number
Employer Contact Email
Description
Reason for leaving
Professional References
Reference 1:
Name
Phone
Email
Relationship
How long have you known this individual?
Reference 2:
Name
Phone
Email
Relationship
How long have you known this individual?
Please "Select" all statements below that you understand and agree too.
I understand that if given the opportunity for employment that I may be subjected to a drug screen test at time of hire and randomly throughout my employment with Mountain States EMS
I understand and authorize for an employment opportunity that I will be subjected to a thorough background check and attest that all information I have provided to be correct and true. Any false claims will result in disciplinary action, up to termination
I attest that I am capable of all physical lifting, sitting, standing, bending, ect. Requirements of this position
Send
