application

Position(s) applied for:

Today's Date

Name

Email

Home Phone

Mobile Phone

Social Security Number

Street Address

City

State

Zip

Are you at least 18 years old?

Yes No

Have you ever been employeed here before?

Yes No

If yes, dates of employment and positions held

Are you legally eligible for employment in this country?

Yes No

Dates available for employment

Desired Salary Range

Type of Employment Desired

Full Time Part Time Per-Diem Office / Admin

Previous Education

Previous Employment: Starting with your most recent employer, assignment or volunteer activities provide the following information: From and To Dates of employment, Job Title, Employer name, address, phone, supervisor. Reason for leaving, Hourly rate, job responsibilities

Employment 1

May we contact this employer for reference?

Yes No

Employment 2

May we contact this employer for reference?

Yes No

Employment 3

May we contact this employer for reference?

Yes No

Education

High School: Name, City/Town, State, Years Completed, Disploma Obtained, GED?

Undergraduate College: Name, City/Town, State, Years Completed, Disploma Obtained, GED?

Post Graduate College: Name, City/Town, State, Years Completed, Disploma Obtained, GED?

Trade or Technical School: Name, City/Town, State, Years Completed, Disploma Obtained, GED?

References

Reference 1: Name, Years Known, Relationship, Telephone

Reference 2: Name, Years Known, Relationship, Telephone

Reference 3: Name, Years Known, Relationship, Telephone

EMS Experience

EMS Experience 1: Dates, position, agency name, phone, supervisor, title, career or voluinteer, reason for leaving

May we contact for reference?

Yes No

EMS Experience 2 Dates, position, agency name, phone, supervisor, title, career or voluinteer, reason for leaving

May we contact for reference?

Yes No

EMS Experience 3 Dates, position, agency name, phone, supervisor, title, career or voluinteer, reason for leaving

May we contact for reference?

Yes No

Certifications

EMT (required)

Issuing State

Years Cert Held

Expiration Date

Nat Registry (Y/N?)

EMT-Paramedic

Issuing State

Years Cert Held

Expiration Date

Nat Registry (Y/N?)

CPR (required)

CPR Program

AHA ARC ASHI

Issuing Agency

Expiration Date

Drivers License (required)

Issuing State

Expiration Date

Class

Operator's Number

Good Standing

Yes No

The Trenton Emergency Medical Service requires the following certifications within one year of employment: haz mat operations, WMD Awareness, CEVOII or EVOC IMS 700, PHTLS or BTLS, PEPP.

Are you willing to comply with these training requirements?

Yes No