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Employment Application
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Employment Application
Employee Application
You must have current copies of all of your certifications in PDF format and your Missouri Criminal Background Check in order to submit this application. Applicants are considered for all positions without regard race, color, religion, sex, national origin, age, veteran status, disability, or any other factor which is prohibited by Missouri or federal law. The St. Francois County Ambulance District is an equal opportunity employer. This application will remain active for one year from the date it is submitted. If you wish to be considered for employment after that time, you will need to submit a new application.
Date of Application
*
MM slash DD slash YYYY
Position Applying For
*
EMT-B
Paramedic
RN
Have you previously applied and/or worked for St. Francois County Ambulance District?
*
Yes
No
Legal Name
*
Last
Middle Initial
First
Address
*
Physical Address
Mailing Address
City
State / Province / Region
ZIP / Postal Code
How long have you lived at this address?
*
Previous Addresses For Past 5 Years
Previous Address
Move In Date
Move Out Date
Please use the plus icon at the end of the line to enter additional addresses.
Current Email
*
Enter Email
Confirm Email
Phone Number #1
*
Phone Number #2 (optional)
Social Security Number
*
Do you have a valid Missouri driver's license?
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Yes
No
Have you ever had a license revoked? (Driver's License &/OR Professional Licenses) If you answer "YES" please 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.
*
Yes
No
Upload a current copy of your valid Driver's License
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Employment Information:
Are you available for shift work?
Yes
No
This includes, but not limited to overnight hours.
Are you available to work on weekdays?
Yes
No
Monday - Friday
Are you available to work on holidays?
Yes
No
New Year's, Memorial Day, Labor Day, Thanksgiving, Christmas, etc.
Are you willing to work 12-18 hour shifts?
Yes
No
Our normal shifts are 12 hours, however, you may be asked to work 18 consecutive hours.
Are you either a citizen of the United States or an alien who is authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a felony crime, or a crime involving dishonesty or lack of truthfulness or involving a health service function? (Include any probation, SIS, guilty plea, plea of non contendere, etc.)
*
Yes
No
If yes, please provide explanation:
Have you ever been convicted of, admitted, committing or awaiting trial for any crime?
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Yes
No
If yes, please provide explanation:
Upload a copy of your Missouri State Highway Patrol Criminal Record Check
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please visit www.machs.mo.gov to obtain a criminal record check. Print and upload a copy of the document here.
Most Recent Employer:
Give accurate, complete full time and part time employment history starting with present or most recent employer.
Ensure each file type has a unique file name. You cannot upload the same file in multiple fields. The system will reject it.
Have you ever served in the military?
Yes
No
Are you currently employed?
Yes
No
Company Name
Telephone
Address
Supervisor's Name
City/State/Zip
Dates Employed
Job Title
Ending Salary
Job Description
May we contact?
Reason for Leaving
Employer #2
Company Name
Telephone
Address
Supervisor's Name
City/State/Zip
Dates Employed
Job Title
Ending Salary
Job Description
May we contact?
Reason for Leaving
Employer #3
Company Name
Telephone
Address
Supervisor's Name
City/State/Zip
Dates Employed
Job Title
Ending Salary
Job Description
May we contact?
Reason for Leaving
Employer #4
Company Name
Telephone
Address
Supervisor's Name
City/State/Zip
Dates Employed
Job Title
Ending Salary
Job Description
May we contact?
Reason for Leaving
Education Information
High School
Location
Dates Attended
Years Completed
Degree or Diploma
Comments and/or Area of Specialty
College/University
Location
Dates Attended
Years Completed
Degree or Diploma
Comments and/or Area of Specialty
Graduate School
Location
Dates Attended
Years Completed
Degree or Diploma
Comments and/or Area of Specialty
Trade/Professional
Location
Dates Attended
Years Completed
Degree or Diploma
Comments and/or Area of Specialty
EMS Education Information
EMT-B/Paramedic/RN
*
Date Expires
License/Certification # if Applicable
Must possess a current Missouri License
Missouri Clinical License
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your license.
NRP or National Registry
Date Expires
License/Certification # if Applicable
NRP or NREMT
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your license.
AHA - BLS Provider
*
Date Expires
Must possess a current BLS Certification
BLS Provider
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your certification.
AHA - ACLS
Date Expires
Must possess a current ACLS Certification (Paramedic)
ACLS Provider
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your certification.
AHA - PALS
Date Expires
Must possess a current PALS Certification (Paramedic)
PALS Provider
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your certification.
PHTLS or ITLS
Date Expires
PHTLS or ITLS
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your certification.
PEPP
Date Expires
PEPP
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Please upload a current copy of your certification.
Please upload each FEMA NIMS document in its own section accordingly.
FEMA NIMS 100c
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
*Required.
FEMA NIMS 200c
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
*Required.
FEMA NIMS 700b
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
*Required.
FEMA NIMS 800d
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
*Required.
FEMA NIMS Hazmat .00005A
*
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Alternate Hazmat Materials Certification
Accepted file types: jpg, pdf, Max. file size: 10 MB.
Do agree that if employed, that you will maintain all required certfications?
*
Yes
No
References
List three references that are NOT related to you and have definite knowledge of your personal and professional job history.
*
Name (Last. First)
Address
Phone Number
E-Mail Address
How Long Have You Known Them
Please use the plus icon at the end of each line to add additional references.
Do you agree to a physical exam including drug and/or alcohol screening at company expense evaluating the bone fide occupation qualifications of the position?
*
Yes
No
List any professional, trade or service organizations in which you are a member of. If you think participation would be helpful to us in considering for your employment. (i.e. organizing activities, non-profit work, accomplishments, leadership or etc.):
Applicant Information Accuracy and Acknowledgment Signature Verification
Date
MM slash DD slash YYYY
Applicant Information Accuracy and Acknowledgment Signature Verification
*
I agree and consent to the following employment statement.
By selecting this box, you hereby certify and believe to the best of your knowledge the answers given to the foregoing questions and all statements in this application are correct.
If employed, you agree that all material created and produced, all inventions new or changes in processes developed, during your employment, whether in written, graphic, or broadcasting form, are the exclusive property of St. Francois County Ambulance District. The St. Francois County Ambulance District is entitled to use and/or sell and that subsequent to your employment with St. Francois County Ambulance District you will not disclose, use, or reveal any confidential information related to St. Francois County Ambulance District without first obtaining written consent from the Administrator of St. Francois County Ambulance District.
You hereby apply for employment upon the basis and understand that such employment may be terminated at any time upon notice given to you personally, or sent to your last known address.
You further consent with St. Francois County Ambulance District or its agents, may obtain personal and job related information that is relevant to the consideration of this application for employment.
Signature
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