EMPLOYMENT APPLICATION MedCoast Ambulance is an equal opportunity employer and selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, age, veteran status, ancestry, marital status, or disability. MedCoast Ambulance will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability, unless the accommodation will impose an undue hardship on the operation of our business. CONTACT INFORMATION Name Last* Middle First* Current Address Street City State Zip Telephone Daytime Evening Email Address SSN # Are you over 18 years of age? yesno (The law prohibits discrimination against anyone at least 40 or more years old) Have you ever applied or were employed at MedCoast Ambulance before? yesno If yes When? Position? Do you have any relatives working for MedCoast Ambulance? lf yes, which location/department? EDUCATION AND TRAINING High School Name City Year Completed Degree College Name City Year Completed Degree Course/Major Subject EMT School/Training Name City Year Completed Position you are applying for? Position Title How did you learn of this position? When can you start? Are you seeking Full TimePart TimeTemporary EmploymentNo Preference Hours/Shifts Available: PLEASE READ AND COMPLETE CAREFULLY 1. Are you legally eligible for employment in the U.S.? yesno 2. Have you ever been fire or asked to resign from any job? lf yes, please list employer, date, and reason below yesno 3. Have you ever been convicted of a felony? yesno 4. ls there any reason that you could not adequately perform the essential duties of the job for which you have applied? yesno 5. Have you ever been excluded or debarred from practicing within a federal healthcare program? If yes list term and reason for exclusion below. yesno PLEASE COMPLETE THIS SECTION IF THE JOB FOR WHICH YOU ARE APPLYING MIGHT REQUIRE YOU TO DRIVE COMPANY VEHICLES 6. Do you have a valid driver's license? If yes, please list state, number, expiration date, and type/endorsement. yesno State Number Expiration Type/Endorsement 7. Have you been cited for any moving violations in the last three years? yesno 8. Have you had any accidents in the last three years? yesno 9. Has your driver's license ever been suspended, revoked, denied or canceled? yesno APPLICANT EEO OR AFFIRMATIVE ACTION INFORMATION It is the policy of MedCoast Ambulance Service to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, gender, age, ancestry. sexual orientation, veteran status, marital status. or disability. Various agencies of the government require employers to invite applicants to identify themselves as indicated below. Completion of this form is voluntary and in no way affects the decision regarding your application for employment. Employment History: Complete information ,including contact numbers, will assist in timely verification Employer #1 Employer Address City/State Supervisor's name Supervisor's phone # Employed From Employed to Hourly Rate Position/Title Responsibilities Reasons for Leaving May we contact this employer? yesno Employer #2 Employer Address City/State Supervisor's name Supervisor's phone # Employed From Employed To Hourly Rate Position/Title Responsibilities Reasons for Leaving May we contact this employer? yesno PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING. This form is confidential and will be maintained separately from your application form. I CERTIFY that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my immediate dismissal if discovered at a later date. I UNDERSTAND that a consumer report may be obtained for employment purposes (including criminal, education, and employment background checks) as part of the pre-employment investigation and at any time during my employment. I understand that should this application or a criminal record check reveal a conviction, finding or plea of guilt, deferral, no contest or nolo contendre of a crime, further processing of this application or my employment if hired, may be terminated. If I am offered employment. I will, as a condition of employment be required to submit proof of my identity and legal right to work in the U.S. I UNDERSTAND that I will be required to possess a current and valid driver's license if my job requires me to drive in the course of my work. I AUTHORIZE the investigation of any or all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations from any legal liability in making such statements. I hereby fully waive any rights or claims I have or may have against all current and/or former employers, and their agents, employees, and representatives and damages that may directly or indirectly result from the use, disclosure or release of any information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claim against MedCoast Ambulance and any outside agency utilized by MedCoast Ambulance as a result of any information that is obtained in this investigation. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE, AT THE OPTION OT THE COMPANY OR MYSELF. Full Legal Name* Electronic Signature* Type your First & Last Name * By checking this box, you, the applicant for this form, warrant the truthfulness of the information provided in this application. By typing your First and Last Name you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.