16945 Sherman Way
Van Nuys, CA 91406
(818) 996-2200

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Employment Application
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Personal Information
*First / Last Name:
*Phone Number: (including area code) (xxx-xxx-xxxx)
Driver's License:
Referred By:
Emergency Contact
Phone Number: (including area code) (xxx-xxx-xxxx)
Employment Desired
Type of Employment?:
Are you currently Employed?:
*Position Applying for:
Personal Background
Have you previously applied here?:
Do you have any friends or relatives working for us?:
Are you at least 18 years of age?

Can you provide proof after you are hired that you can legally work in the United States?

Have you previously worked for an ambulance service?:
if Yes, What Ambulance Service? (name and dates):
Have you ever been convicted of a felony or any crime ?:
What days and hours are you available to work ?  
Monday Hours:
Tuesday Hours:
Wednesday Hours:
Thursday Hours:
Friday Hours:
Saturday Hours:
Sunday Hours:
Are you available to work weekends?          
Are you available to work Overtime?    
When can you start to work if hired?          
Salary Desired:
Have you been cited in any moving violation in the last 3 years ?
Have you had any accidents in the last 3 years ?
Has your Driver's License ever been suspended, revoked, denied or cancelled ?
Please write or Paste your Resume in the box provided:
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