Columbus and Central Ohio Ambulance and Medical Transport | Critical Care Transport

Please complete this online application:

Email Address *

Full Name: *
First, Middle, Last Name
Social Security Number: *
Street Address: *

City:

State:

Zip Code:

Daytime Phone:

Mobile Phone:

Are you at least 18 years of age? Yes No

Hours Requested Full Time Part Time

Date Available to Start:

How did you find out about this position?

Do you have relatives of friends working/volunteering here? Yes No

Please List:

POSITION INFORMATION
Positions(s) Applying For:
Have you ever worked/volunteered for this organization? Yes No

If so, date(s):

Prior position(s) here:

Reason(s) for leaving:
CERTIFICATION INFORMATION
(List only current certifications - photocopies required at interview)

Certification (1)

Certification Number (1)

Expires On (1)
Month/Year

Certifying Agency (1)

Certification (2)

Certification Number (2)

Expires On (2)
Month/Year

Certifying Agency (2)

Certification (3)

Certification Number (3)

Expires On (3)
Month/Year

Certifying Agency (3)

Certification (4)

Certification Number (4)

Expires On (4)
Month/Year

Certifying Agency (4)

Certification (5)

Certification Number (5)

Expires On (5)
Month/Year

Certifying Agency (5)

Certification (6)

Certification Number (6)

Expires On (6)
Month/Year

Certifying Agency (6)

Certification (7)

Certification Number (7)

Expires On (7)
Month/Year

Certifying Agency (7)

Certification (8)

Certification Number (8)

Expires On (8)
Month/Year

Certifying Agency (8)

Certification (8)

Certification Number (8)

Expires On (8)
Month/Year

Certifying Agency (8)

WORK REQUIREMENTS & GENERAL INFORMATION
Can you provide proof, if hired, that you are eligible to work in the U.S.? Yes No

Do you have a valid Driver's License? Yes No

Class:

Driver's License #:

State:

List all moving violations (convictions) and accidents and any suspensions or revocations
of your license in the last five years:
Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended? Yes No
If yes, explain:
A conviction will not necessarily disqualify you from employment.
Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid? Yes No
If yes, explain:
EMPLOYMENT HISTORY
(List your last three employers or volunteer activities, starting with the most recent.)
Employer 1:

Job Title (1):

Supervisor (1):

Start Date (1):

End Date (1):

Salary (1):

Job Description (including duties and responsibilities) (1):

Employer's (1) Phone # :

May we contact them? (1) Yes No

Reason for leaving (1):
Employer 2:

Job Title (2):

Supervisor (2):

Start Date (2):

End Date (2):

Salary (2):

Job Description (including duties and responsibilities) (2) :

Employer's (2) Phone #:

May we contact them? (2) Yes No

Reason for leaving (2):
Employer 3:

Job Title (3):

Supervisor (3):

Start Date (3):

End Date (3):

Salary (3):

Job Description (including duties and responsibilities) (3):

Employer's (3) Phone #:

May we contact them? (3) Yes No

Reason for leaving (3):
Explain any gaps in employment:
MILITARY SERVICE:

Branch of Service:

Date Began:

Date Ended:

Rank & Duties:

Date Discharged:

COLLEGE:
College/University:
College/University Address:
Street, City, State, Zip

Did you graduate from college? Yes No

If not, highest year completed:

Degree:

Major:

OTHER COLLEGE:
Other College/University:
College/University 2 Address:
Street, City, State, Zip

Did you graduate? (2) Yes No

If not, highest year completed (2):

Degree (2):

Major (2):

TECHNICAL SCHOOL:
Technical School Name:
Technical School's Address:
Street, City, State, Zip

Did you graduate from Technical School? Yes No

If not, highest year completed (TS):

Certificate:

Tech License:

Tech License Expires:

OTHER SCHOOL/TRAINING:
Other School/Training Name (3):
Address (3):
Street, City, State, Zip

Did you graduate? (3) Yes No

If not, highest year completed (3):

Certificate (3):

License (3):

Expires (3):

Other:

EMS/Fire Service related training
not listed above:

EMS/Fire/Professional Affiliations:
other than listed under prior employment

Describe any additional qualifications or information, personal or professional,
that you feel would be beneficial for us to know when considering your application:
REFERENCES:
List three persons, other than relatives, who have knowledge of your work experience and/or education.
Reference 1 Name:
Reference 1 Address:
Street, City, State, Zip

Occupation (1):

Years Known (1):

Phone Number (1):
(xxx)xxx-xxxx

Reference 2 Name:
Reference 2 Address:
Street, City, State, Zip

Occupation (2):

Years Known (2):

Phone Number (2):
(xxx)xxx-xxxx

Reference 3 Name:
Reference 3 Address:
Street, City, State, Zip

Occupation (3):

Years Known (3):

Phone Number (3):
(xxx)xxx-xxxx

List two personal references that have known you for at least three years outside work.
Personal Reference 1 Name:
Personal Reference 1 Address:
Street, City, State, Zip

How they know you (1):

Years Known (1):

Phone Number (1):
(xxx)xxx-xxxx

Personal Reference 2 Name:
Personal Reference 2 Address:
Street, City, State, Zip

How they know you (2):

Years Known (2):

Phone Number (2):
(xxx)xxx-xxxx

POSITION INFORMATION

CERTIFICATION INFORMATION

WORK REQUIREMENTS & GENERAL INFORMATION

EMPLOYMENT HISTORY

MILITARY SERVICE:

PAST EMPLOYMENT

EDUCATION AND TRAINING

HIGH SCHOOL:

COLLEGE:

OTHER COLLEGE:

TECHNICAL SCHOOL:

OTHER SCHOOL/TRAINING:

REFERENCES:

List two personal references that have known you for at least three years outside work.