Job Application Contact InfoFirst Name *Last Name *Email *Phone Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountry Work AvailabilityCitizenship Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)YesNoRequested Weekly Hours *Desired full-time or part-time employment?Full-TimePart-TimePreferred Shift *FirstSecondThirdFirst SwingSecond SwingHours Available 10-2020-3030-4040-5050+Holidays Are you willing to work weekends or an occasional Holiday for higher wages?YesNo EMT Certifications & LicensesEMT Certified NoneBasicInterimMedicCPR Certified NoYesFirst Aid NoYes Criminal BackgroundConviction Have you ever been convicted of a crime?NoYes, a felonyYes, a midemeanorConviction Details If you have been convicted of a felony or misdemeanor, please provide date(s) and describe events. Employment DetailsDesired PositionDesired Position Position being applied for:Referral How did you hear of this opening?Previous Application Have you ever applied for, or worked for Ohio Medical Transport, LLC?NoYesAvailable Start Date Expected Hourly Wage List Applicable Skills Performance Are you aware of anything that might hinder your ability to effectively perform work with Ohio Medical Transport, LLC ?NoYesIf yes, describe what might hinder your performance Current EmploymentPresent Employment Are you presently employed?NoYesContact Employer May we contact your present employer?YesNoEmployer Contact Name Employer Contact Phone EducationHigh SchoolSchool Name, City, State Year Major & Degree CollegeSchool Name, City, State Year Major & Degree Other TrainingSchool Name, City, State Year Major & Degree Additional ExperienceRelevant Experience In addition to your work history, are there are other skills, qualifications, or experience that you believe would make you well-suited for work with Ohio Medical Transport, LLC?Continuing Education Are you planning to continue your educational studies?NoYes Work ExperiencePlease enter employment history, starting with the most recent... Company #1Company Name, Address, City, State Phone Start Date End Date Starting Wage Ending Wage Starting Position Ending Position Name of Supervisor May we contact your previous supervisor? YesNoSupervisor Phone Number Responsibilities Reason for Leaving Company #2Company Name, Address, City, State Phone Start Date End Date Starting Wage Ending Wage Starting Position Ending Position Name of Supervisor May we contact your previous supervisor? YesNoSupervisor Phone Responsibilities Reason for Leaving Company #3Company Name, Address, City, State Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryPhone Start Date End Date Starting Wage Ending Wage Starting Position Ending Position Name of Supervisor May we contact your previous supervisor? YesNoSupervisor Phone Responsibilities Reason for Leaving Company #4Company Name, Address, City, State Phone Start Date End Date ReferencesReference #1Name Phone Years Known Address, City, State, Zip Reference #2Name Phone Years Known Address, City, State, Zip Reference #3Name Phone Years Known Address, City, State, Zip Submit ApplicationPlease Read Before Submitting I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required. I understand that employment at this company is “at will,” which means that either I or Ohio Medical Transport, LLC can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.Full Name Social Security # Email Email VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
