Return completed applications to:
Tri Med Ambulance
A
ttn: Recruiting Department
18821 East Valley Hwy
Kent, WA 98032
HR DEPARTMENT ONLY
Date Received
NOTE: PLEASE ASK IF YOU NEED ASSISTANCE COMPLETING THIS APPLICATION
INFORMATION
LAST NAME: FIRST NAME: MIDDLE IN:
PRESENT ADDRESS: CITY: STATE ZIP:
HOME OR MESSAGE PHONE: WORK: E-MAIL:
SOCIAL SECURITY NUMBER: WAGE/SALARY DESIRED?:
POSITION APPLIED FOR? DATE AVAILABLE FOR WORK?
AVAILABLE: Days  Evenings  Nights  APPLYING FOR: Full time  Part time  Temporary
Will visa or immigration status prevent lawful employment? Yes  No  (Proof of right to work in the U.S. will be required if hired.)
Are you 21 years or older? Yes  No  (If no, employment is subject to minimum legal age requirements.)
Do you have a Non-Compete, Non-Disclosure, or other agreement that might restrict your employment with us? Yes No
Have you ever previously applied to or been employed by this company? Yes No If yes, when?
How did you learn about this position opening?
Were you known by any other name at any job or school listed on this application? What name(s)?
At which school(s)/employer(s) were you known by this other name?
EDUCATION
Name and Location of School Years Completed
Did you
graduate?
Degrees Received
High School
College
Trade
Business, or
Graduate school
ADDITIONAL INFORMATION.
Summarizes special job related skills acquired from employment or other experience. E.g. US Military
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____________________________________________________________________________________________________
__________________________________________________________________________________________________________
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EQUAL OPPORTUNITY EMPLOYER
EQUAL OPPORTUNITY EMPLOYER
EMPLOYMENT RECORD (INCOMPLETE APPLICATIONS CANNOT BE ACCEPTED)
Please list your employment history below beginning with the most recent employer, include U.S. military service.
If currently employed, may we contact your employer? Yes  No 
Employer
Type of business Telephone ( )
City State Fax: ( )
Job Title Supervisor Telephone ( )
Dates Employed: From To Reason for leaving Wage/Salary
Duties
Employer Type of business Telephone ( )
City State Fax: ( )
Job Title Supervisor Telephone ( )
Dates Employed: From To Reason for leaving Wage/Salary
Duties
Employer
Type of business Telephone ( )
City State Fax: ( )
Job Title Supervisor Telephone ( )
Dates Employed: From To Reason for leaving Wage/Salary
Duties
I certify that the information given by me is true and complete to the best of my knowledge. I understand that if I am employed, the
discovery that I gave false information during the application process may result in immediate dismissal.
I authorize Tri-Med Ambulance to which I am providing this application to investigate all statements contained in this application and to
request information about me from previous employers, educational institutions, and references. I expressly
authorize my previous
employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including Tri-Med
Ambulance) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason,
arising out of furnishing any information. If employed, I release the Company from any liability for future references it may provide
regarding my work history with the Company.
Due to the large number of applications that T
r
i Med Ambulance receives, I understand Tri Med Ambulance cannot guarantee that my
application will be considered for any or all open positions they may have or that my application will be considered for any specific time.
In the event of employment, I understand that I am required to abide by
all current and subsequently issued rules and regulations of the
Company and that my employment and compensation may be terminated, at any time, with or without notice, by either party.
Signature of Applicant Date
© 1992 PERSONNEL MANAGEMENT SYSTEMS, INC. 04/01
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signature
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