Employment Application

Step 1 of 15

Your Legal Name(Required)

First Middle Initial Last

Social Security Number

If you do not not feel comfortable providing your SSN, we can obtain it later.

Contact Information

Phone Number(Required)

When is The Best Time to Call You(Required)

Mornings

Early Afternoon

Late Afternoon

Early Evening

Call Me Anytime

Your Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your mailing address different than your street address(Required)

Yes

Please Provide Your Mailing Address(Required)

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code

How long have you lived at your current address?(Required)

Less than 5 years

5-10 years

Greater than 10 years

Previous Address

Since you have been at your current residence less than 5 years, we need to get a little more information from you. Please list each of the additional addresses you have lived at in the last 5 years on the next screen. Select the plus sign to add additional addresses.

Previous Address(Required)

Use the “+” icon to add each additional address.

Address, City, State, Zip

Move In Date

Move Out Date

Which Position Are You Applying For?(Required)

Paramedic

EMT-B

Account Manager

Are You Interested In A Full-time or Part-Time Position?(Required)

Full-Time

Part-Time

Full-Time or Part-Time

Have You Previously Applied For St. Francois County Ambulance District(Required)

Yes

Estimated Date of Previous Application(Required)

Have you previously been employed by St. Francois County Ambulance District(Required)

Yes

When did you leave our company?(Required)

Reason for leaving?(Required)

Scheduling and Availability

Are You Available For Shift Work?(Required)

Most shifts worked will be 12 hours in duration and may consist of dayshift, mid day/evening, and night shift.

Yes

Are You Available To Work Weekdays, Weekends, and Holidays?(Required)

Yes

Please Explain:

Are You Willing To Work 12-18 Hour Shifts?(Required)

Normal shifts are 12 hours, however, you may be asked to work 18 consecutive hours.

Yes

Hours You Are Available for Work(Required)

Please tell us what time frames you are available for work each day of the week. If you are not limited on the hours you can work, just put “Open” or “Any” in each box.

Monday

Tuesday

Wednesday

Thursday

Friday

Background Information

Are you either a citizen of the United States, or an alien who is authorized to work in the United States?(Required)

Yes

Have you ever served in the military?(Required)

Yes

Have you ever been convicted of a felony crime, a crime involving dishonesty or lack of truthfulness, or involving a health service function?(Required)

This includes any probation, SIS, guilty plea, plea of non contendere, etc.

Yes

Please provide a detailed explanation:(Required)

Have you ever been convicted of, admitted to, or are you awaiting trial for any crime?(Required)

Yes

Please provide a detailed explanation:(Required)

Do you agree to a physical exam, including drug/or alcohol screening, at company expense evaluating the bona fide occupation qualifications of the position?(Required)

Yes

Upload a copy of your Missouri State Highway Patrol Criminal Record Check(Required)

Please visit https://www.machs.mo.gov to obtain a criminal record check.

Accepted file types: pdf, jpg, jpeg, jpeg, Max. file size: 1 GB.

Employment History

Are You Currently Employed(Required)

Yes

Current Employer

Company Name(Required)

Job Title(Required)

Current Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Supervisor's Name(Required)

Dates Employed(Required)

Salary(Required)

Job Description(Required)

May We Contact Your Employer?(Required)

Yes

Reason For Leaving(Required)

If still employed, just state “Still Employed”

Previous Employment

Did you have any employers prior to your current Employer?(Required)

If you have not had any previous employment, select “No.”

Yes

Previous Employers

Your Previous Employers(Required)

Please list your previous employers starting with the most recent. Include the dates you worked and the position you held. Select the plus sign to add each additional employer.

Employer

Dates

Position

Phone

Reason For Leaving

May We Contact Your Previous Employers?(Required)

Yes

Education

Do You Have A High School Diploma or GED Equivalent?(Required)

Diploma

GED

I Do Not Have A Diploma or GED

High School(Required)

School Name

Dates Attended

Did You Obtain Your Diploma?

Did You Attend A College/University?(Required)

Yes

College/University(Required)

School Name

Dates Attended

Years Completed

Did You Obtain A Degree or Certificate?

Comments and/or Area of Specialty

Did You Attend a Technical/Trade School(Required)

Yes

Technical/Trade School(Required)

School Name

Dates Attended

Years Completed

Did You Obtain A Degree or Certificate?

Comments and/or Area of Specialty

Job Specific Education

Do You Have Any EMS Related Education(Required)

Yes

Please Explain(Required)

Do You Have Any Medical Billing and Coding Training and/or Experience?(Required)

Yes

Please Explain(Required)

Which EMT Program Did You Attend?(Required)

Name of Program

City/State

Year Completed

Which Paramedic Program Did You Attend?(Required)

Name of Program

City/State

Year Completed

Licensures and Certifications

Have You Ever Had A License Revoked? (Driver's License &/or Professional Licenses)(Required)

Yes

Which Licensure/certification was revoked?(Required)

Please Explain:(Required)

Provide the date of the proceedings, name address and phone number of agency or body where the proceedings took place, accusations against you, and the final disposition.