PERSONAL INFORMATION

Email Address:

Date:
Name:
Last	First	Middle
Present Address:
Street:
City:	State:	Zip:
Phone:	Social Security #:

	Yes	No
Are you legally eligible for employment in the USA?
Are you over 18 years old?
If applying for a driving position, are you over 21?
Have you been convicted of an offense punishable as a felony?
If yes, explain:
Do you have a medical or physical condition which would prevent you from satisfactorily performing the job applied for?
If yes, explain:
Have you received compensation for any injuries?
If yes, describe:

POSITION(S) APPLIED FOR:
REQUIRED PAY:
AVAILABLE TO WORK:	Part-time      Full-time      Shift      Temp

	Yes	No
Are you willing to work overtime as required?
Are there any hours, shifts or days you cannot or will not work?
If yes, explain:
Have you ever worked for SLAS before?
If yes, give date(s):

List any friends or relatives working for us, other than spouse:

If your application is considered favorably, on what date will you be able to work?

Are there any experiences, skills, or qualifications which you feel would especially fit you for work with SLAS?

LICENSES - CERTIFICATES - PERMITS

		Exp. Date
Valid CA Driver's License #
Valid CA Ambulance Driver Certificate
Emergency Medical Technician 1A Certificate
Medical Examiner's Certificate
Emergency Medical Technician II Certificate
Paramedic (EMT-P) Certificate
County:
Basic Cardiopulmonary Resuscitation CPR
Advanced Cardiac Life Support/CPR A.C.L.S.
Please list other certificates of training, including skills from the military:

San Luis Ambulance Service, Inc. will require you to take an EMT-1A or EMT-P skills test written) prior to consideration for employment. The test is approved by the San Luis Obispo County Emergency Medical Services Agency (EMSA).

Due to the nature of the ambulance service business, employees are often scheduled to work holidays such as Christmas and Thanksgiving. Are you willing to accept scheduled work on a holiday?

Yes

No

From time to time, it may be necessary for an employee to work unscheduled overtime. Therefore, in accepting employment with SLAS, all employees assume an obligation to work not only regular shift assignments but occasional overtime assignments whenever it may become necessary.

EDUCATION

Level	Name and Location of School		Years Attended		Major	Diploma or Degree
High School	Name: Location:		From: To:
College	Name: Location:		From: To:
Paramedic/EMT School	Name: Location:		From: To:
Other	Name: Location:		From: To:

Indicate any foreign languages you can speak, read and/or write.

	Fluent	Good	Fair
Speak
Read
Write
American Sign

MILITARY SERVICE RECORD

Were you in the U.S. Armed Forces?	Yes		No
If yes, which branch?
Dates of duty:	From:		To:
Rank at time of discharge:
List duties in the service, including special training:
Are you currently an active member of the National Guard or Reserves?	Yes		No

EXPERIENCE AND EMPLOYMENT

Beginning with your most current employment, please list all jobs (including part-time, temporary, and voluntary positions) you have held. For identification and verification, please indicate the nature of the activity, i.e., full-time, or voluntary. If you have had intervening periods of military service or unemployment, please list those periods in sequence in the spaces provided. Do not omit any period of employment.

Dates of Employment	Name and Address of Employer	Name of Supervisor
From: To: Full Time Part Time Voluntary	Name: Address: Phone: Duties:	Name: Name(s) of Co-worker(s):
Reason for leaving:
Military Service:   From: Not Employed:   To:

Dates of Employment	Name and Address of Employer	Name of Supervisor
From: To: Full Time Part Time Voluntary	Name: Address: Phone: Duties:	Name: Name(s) of Co-worker(s):
Reason for leaving:
Military Service:   From: Not Employed:   To:

Dates of Employment	Name and Address of Employer	Name of Supervisor
From: To: Full Time Part Time Voluntary	Name: Address: Phone: Duties:	Name: Name(s) of Co-worker(s):
Reason for leaving:
Military Service:   From: Not Employed:   To:

Dates of Employment	Name and Address of Employer	Name of Supervisor
From: To: Full Time Part Time Voluntary	Name: Address: Phone: Duties:	Name: Name(s) of Co-worker(s):
Reason for leaving:
Military Service:   From: Not Employed:   To:

APPLICANT'S STATEMENT

Please read 

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed forty-five (45) days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization 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 cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I hereby understand all applicants may be subject to an in-depth physical exam.

In the event of employment, I understand that false, missing or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer.

REFERENCES

Provide the name, address and telephone number of two individuals who can attest to your good character. Do not list individuals who are employees of San Luis Ambulance Service, Inc. or relatives.

Name	Address	Phone	Years Known

GENERAL INFORMATION AND FACTS

I understand and agree that:

1. I am aware that ambulance employees are subject to heavy lifting, often under adverse conditions.
2. I am aware that ambulance employees are often subject to working shifts of more than forty-eight (48) consecutive hours.
3. I am aware that ambulance employees are often subject to transporting persons with contagious illnesses and/or diseases.
4. I am aware that the sleeping facilities provided by San Luis Ambulance Service, Inc. to ambulance employees are not segregated on the basis of employees' race, color, religious belief, sex, national origin, age, ancestry, marital status or handicap.
5. I am aware that San Luis Ambulance Service, Inc. will make a thorough investigation of my entire employment and personal history and may verify all data given in my application for employment, related papers or oral interviews. I authorize such investigation and the giving and receiving of any information requested by San Luis Ambulance Service, Inc. Additionally, I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate termination.
6. I agree that my employment may be terminated by San Luis Ambulance Service, Inc. at any time without liability for wages or salary except such as may have been earned at the date of such termination.
7. I agree that if requested by the president or general manager of San Luis Ambulance Service, Inc., I will submit to a search of my person or of any locker that may be assigned to me, and I hereby waive all claims for any damages on account of such examination.
8. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered for prior to employment or in the future during my employment with San Luis Ambulance Service, Inc.
9. It is my understanding that employees of San Luis Ambulance Service, Inc. who are suspected of intoxication for any reason while on duty or prior to going on duty may be subject to a medical examination and alcohol or drug screening. Such examinations and/or tests, when requested, will be a condition of employment. Medical/test expenses will, of course, be paid by San Luis Ambulance Service, Inc.
10. It is my understanding that if employed, such employment is for an indefinite period of time and that San Luis Ambulance Service, Inc. can change wages, benefits and employment conditions at any time.
11. It is my understanding that although San Luis Ambulance Service, Inc. makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift work, a rotating schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my employment.
12. It is my understanding that I must submit photocopies of my Ambulance Driver Certificate, CPR card, Medical Examiner's Certificate, EMT card, Department of Motor Vehicles driving record and any other licenses, permits or certificates of training that I may hold, to San Luis Ambulance Service, Inc. as a condition of employment.

CHP - AMBULANCE DRIVER'S HANDBOOK

1106

1. Owner's Responsibility: Every owner, operator, director or employee of an ambulance service shall comply with all provisions of this article and shall be responsible for prohibiting any person in the employ of such service from:
   1. Driving an ambulance when not thoroughly familiar with the provisions of sections 21055, 21056, 21806, 21807, and 23103 of the vehicle code.
   2. Acting at any time in the capacity of an ambulance attendant when such person:
      1. Is required to register as a sex offender under the provision of Sections 290 of the Penal Code.
      2. Habitually or excessively uses or is addicted to the use of narcotics or dangerous drugs, or has been convicted of any offense relating to the use, sale, possession, or transportation of narcotics, habit-forming or dangerous drugs.
      3. Continuously or excessively uses intoxicating beverages.
      4. Has been convicted of any offense punishable as a felony or has been convicted of theft in either degree during the preceding ten-year period.
      5. Has committed any act involving moral turpitude.
      6. Does not comply with the ambulance attendant qualification requirements in section 1101.2 of this article.

I have read the above regulations as reprinted from the Ambulance Driver's Handbook published by the California Highway Patrol and declare under penalty of perjury that the following statements are true and correct.

1. I am not required to register as a sex offender.
2. I do not habitually or excessively use or am I addicted to the use of narcotics or dangerous drugs, or have I ever been convicted of any offense relating to the use, sale, possession, or transportation of narcotics, or dangerous drugs.
3. I do not continuously or excessively use intoxicating beverages.
4. I have never been convicted of any offense punishable as a felony or have I ever been convicted of theft in either degree.
5. I have never committed any act involving moral turpitude.

As an applicant for a position on the ambulance, I realize physical agility and strength are of prime importance for the desired position. Therefore, I shall not hold San Luis Ambulance Service, Inc., its officers, employees and/or agents responsible for any injury sustained directly or indirectly by attempting to qualify for said employment. 

EMPLOYMENT DATA RECORD

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.

As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

VOLUNTARY SURVEY

Date:

Government agencies at times require periodic reports on the sex, ethnicity, handicap, veteran and other protected status of employees. This data is for statistical analysis with respect to the success of the Affirmative Action Program.

SUBMISSION OF THIS INFORMATION IS VOLUNTARY.

Name:
Address
City	State	Zip	Social Security #:

RACE/ETHNIC ORIGIN:

	WHITE:	All persons having origins in any of the original peoples of Europe, N. Africa or the Middle East.
	BLACK:	Persons having origins in any of the Black racial groups.
	ASIAN OR PACIFIC ISLANDER:	Persons with origins in any of the original peoples of the Far East, Southeast, the Indian Subcontinent, or the Pacific Islands.
	AMERICAN INDIAN OR ALASKAN NATIVE:	Persons with origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
	HISPANIC:	Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish Culture or origin regardless of race.

ADDITIONAL INFORMATION:

YES	NO
		Handicapped:	(Describe)
		Vietnam Era Veteran
		Disabled Veteran