* = Required Information

Date:


First Shift
Second Shift
Third Shift
WeekHour

YesNo
YesNo
YesNo
YesNo
YesNo
Full TimePart TimeTemporary
YesNo

EDUCATION
  High School College Technical/Other
School Address
Credits Earned
Major
Diploma/Degree

List below all present and past employment, beginning with your most recent. All times must be accounted for whether employed or not. Attach an additional sheet if necessary.
    1 2 3 4 5 6
Name and Address of Company and Type of Business  
From MO
YR
To MO
YR
Describe in detail work you did and your title  
Weekly Start Salary or Hourly Rate  
Weekly End Salary or Hourly Rate  
Reason for Leaving  
Name, Title and Phone Number of Your Supervisor  

PERSONAL REFERENCES
Name: Company: Phone:
Address: Relationship:
City/State/Zip:
Name: Company: Phone:
Address: Relationship:
City/State/Zip:
Name: Company: Phone:
Address: Relationship:
City/State/Zip:

EMERGENCY CONTACT

APPLICANT'S STATEMENT and CONDITIONS OF EMPLOYMENT
(Please read carefully before signing.)
I understand that an investigative consumer report involving information concerning my character, employment history, general reputation, police record, personal habits, mode of living, credit rating and indebtedness may be obtained prior to any final offer of employment. Upon a timely written request to the personnel department of the company, the nature and scope of the report will be disclosed to me.

I certify that the answers given by me in this employment application are true, correct and complete. I agree that the company shall not be liable, in any respect, if my employment is terminated because of misstatements or pertinent omissions made by me in this application. Moreover, I understand that all offers of employment are contingent upon passing the company's prescribed physical examination and drug screening.

I agree, as a condition of my employment (should I be employed by the Company), to submit to a medical examination if requested and based on the position that I accept, I further agree to the search or examination of myself or personal property while on the company's premises or while conducting its business elsewhere. I also authorize any company, school, police or security personnel, or other person to give any information regarding my employment, habits, ability, or any other characteristics whatsoever, together with any information they have regarding me whether or not it is in their records. I hereby release all physicians, examiners, companies, schools, or other persons from liability for any damages whatsoever for such testing, examining, or issuing this information. It is agreed and understood that completion of this application does not mean a job opening exists and in no way obligates the company to employ me.

In the event of employment, I will comply with all company rules and regulations as established from time to time including the company's substance abuse policy. I am willing to work all assigned overtime or other special work assignments as requested by the company. Furthermore, since the company does not offer contracts of employment (unless signed by the Management), I understand that nothing contained herein is intended to create a contract between the company and me for either employment or the provision of any compensation or benefits. I understand that I have the right to terminate my employment at any time and likewise, the company has the same right.

I hereby understand and acknowledge that any employment relationship with this Company is of an "At-Will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time, with or without notice, and with or without cause. It is further understood that this "At-Will" employment relationship may not be changed by any written document or by verbal agreement unless such change is specifically acknowledged in writing by an authorized Executive of this Company. I also understand that Med Care EMS LLC, retains the right to amend, modify, add, or delete any or all policies or procedures at its sole and absolute discretion.

During my employment with Med Care EMS LLC, and after my employment ends, I agree not to disclose any confidential or proprietary information regarding operating and trade secrets. I further agree that with respect to any civil litigation involving Med Care EMS LLC, in which I am a potential witness and which does not involve an actual or potential claim by me personally, I will not discuss the facts of the case with any third parties without first notifying Med Care EMS LLC, or unless a representative or attorney of Med Care EMS LLC, is present. A copy of this form may be used as the original. The use of results from this form and/or tests will be used for prudent employment decisions.

This application is valid for sixty days from the application date unless renewed in person or in writing.
Applicant's Signature: Date: