Fillable EMPLOYMENT APPLICATION TLC EMERGENCY MEDICAL SERVICES, Inc. WE

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EMPLOYMENT APPLICATION TLC EMERGENCY MEDICAL SERVICES, Inc. WE

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TLC EMERGENCY MEDICAL SERVICES, Inc.
EMPLOYMENT APPLICATION
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Prospective employees will receive consideration without discrimination because of race, creed,
color, sex, age, National origin, marital or veteran status, disability or any other legally protected
status.
PERSONAL INFORMATION
Name Date
Current Address Apt.
City State ZIP
Email
Home Phone incl. Area Code
Cell Phone incl. Area Code
YES NO Are you 18 or older? If you answered "NO," STOP HERE. You must be 18 or older to apply for this job.
YES NO Are you legally authorized to work in the U.S.? (Proof required at time of employment)
YES NO Do you have any relatives/friends working at TLC?
GENERAL INFORMATION
1
Human Resources
TLC Emergency Medical Services Inc.
638 Burnet Ave.
Syracuse, NY 13203
YES NO Are you able to lift 50 pounds?
State: License Number: Type:
INSTRUCTIONS: Please fill out all applicable data while on line using Adobe7 Reader. Leaving blank spaces
may result in application being returned to you. You may submit application by attaching to email addressed
to <HR@tlcems.com>, or printing it out and mailing to:
YES NO Do you have a valid New York State driver's license?
POSITION DESIRED-- Please select from following:
Full Time Part Time: How many hours? Date Available:
EMPLOYMENT HISTORY
(List your last 3 employers or volunteer activities, starting with the most recent.
Include military).
Employer & Address:
Job Title:
Supervisor's Name and Title:
Job Description: (Type of duties/responsibilities)
Employer's Telephone: May We Contact? YES NO
Reason for Leaving:
Employer & Address:
Job Title:
Supervisor's Name and Title:
Job Description: (Type of duties/responsibilities)
Employer's Telephone: May We Contact? YES NO
Reason for Leaving:
2
EMT-B (Level 1) EMT-I (Level 2) EMT-3 Paramedic Dispatcher
Start Date:
End Date:
Start Date:
End Date:
Employer & Address:
Job Title:
Supervisor's Name and Title:
Job Description: (Type of duties/responsibilities)
Employer's Telephone: May We Contact? YES NO
Reason for Leaving:
Explain any gaps in employment:
Have you ever been:
YES NO Placed on probation or terminated for poor performance or absenteeism?
YES NO Disciplined or Fired for insubordination or violating safety rules?
YES NO Disciplined or fired for assault / fighting?
YES NO Disciplined for client or patient abuse?
YES NO Disciplined for alcohol/drug related activity at work? If so, explain:
(Answers of “Yes” for any of the above questions will not necessarily disqualify you
from employment)
3
Start Date:
End Date:
EDUCATION AND TRAINING
HIGH SCHOOL
Name:
Address:
Years Completed: Did You Graduate? YES NO
If not, highest grade completed: Have you received your GED? YES NO
COLLEGE
Name:
Address:
Years Completed: Did You Graduate? YES NO
Major: Minor:
TECHNICAL SCHOOL
Name:
Address:
Years Completed: Did You Graduate? YES NO
Type of Certificate: Expires:
OTHER SCHOOL/TRAINING
Name:
Address:
Years Completed: Did You Graduate? YES NO
Type of Certificate: Expires:
4
OTHER SCHOOLS or CERTIFICATION:
REFERENCES
List 5 people, other than relatives, who have knowledge of your work experience
and/or education.
Name:
Address:
Occupation: Years Known:
Telephone Contact:
Name:
Address:
Occupation: Years Known:
Telephone Contact:
Name:
Address:
Occupation: Years Known:
Telephone Contact:
5
Name:
Address:
Occupation: Years Known:
Telephone Contact:
Name:
Address:
Occupation: Years Known:
Telephone Contact:
List 2 personal references that have known you for at least 3 yrs outside of your work.
Name:
Address:
Occupation: Years Known:
Telephone Contact:
Name:
Address:
Occupation: Years Known:
Telephone Contact:
6
APPLICANT'S AGREEMENT
I hereby affirm that the information provided on this application (and accompanying
resume) is true and complete to the best of my knowledge. I also agree that falsified
information or significant omissions may disqualify me from further consideration for
employment and may be considered justification for dismissal. If discovered at a later
date, employment may be terminated.
Furthermore, I understand that just as I am free to resign at any time, TLC, reserves
the right to terminate my employment at any time, with or without cause and without
prior notice. I also understand that no representative (other than the Owner) of TLC has
the authority to make any assurances to the contrary.
I give the employer the right to investigate all references and to secure additional
information about me, if job related. I hereby release from liability, the employer; its
representatives for seeking such information; and all other persons, corporations or
organizations for furnishing such information.
7
1. Choose "Print" from the File menu.
2. Click the drop-down PDF menu (as
shown at right) and choose "Mail PDF".
3. Enter a "subject" (TLC Application),
the Email address "hr@tlcems.com",
and click "Send".
Mac computer users:
Thanks to your Mac OS X, you can send
yourPDF form by doing the following:
I accept:
I also state that any certificates or licenses submitted are true and complete to the best
of my knowledge.
Save this application to your computer and
attach the saved file to an email addressed to
"HR@tlcems.com".
To digitally sign, click on signature box and create an account as prompted. You must have Adobe
Reader installed on your computer to use this feature.
I also give the employer authorization to procure Motor Vehicle reports at any time
during my employment.
By digitally signing below, I hereby electronically certify that the statements made on
this application form are true and accurate to the best of my knowledge.
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EMPLOYMENT APPLICATION TLC EMERGENCY MEDICAL SERVICES, Inc. WE

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Completed 21 March 2021

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