Oglesby Ambulance Service Application Date: EMTI Basic_ Fulltime_ or Part time Paramedic / Part time EMT_ (Valid Driver'sLicense, Current IDPH License, Currant CPR Card) Paramedic_ (Valid Driver's License, Current IDPH License, Currant CPR Card, Currant ACLS Certificate, Currant Pals or Peep Certifiçate. Last Name Address Home Telephone Birth Date E-Mail Address Name First Name Drivers License # Middle Initial Cell Telephone References - Please give the names and telephone numbers oft three people not related to you whom you have known for at least one year. Telephone Years Known Relationship Employment History Employer Years Worked Duties Reason for leaving In case of emergency- please contact Name Telephone # Are you prevented from lawfully being employed in the United States Yes No Have you been convicted ofa a felony or misdemeanor within the last 5 years Yes No You will not be denied employment solely because of a conviction record; unless the Do youl have any physical limitations that would prevent you: from performing any work offense is related to the job for which you have applied. for which you are being considered? Yes No Ifyes, explain *I certify that the facts contained int this application are true and complete to the best of my knowledge and understand that any false statements on this application are grounds *I give permission for Oglesby Ambulance Service to run a check with local police on *Iauthorize Oglesby Ambulance Service to check with the employers and references listed. Iauthorize them to give you any pertinent information they may have, personal and otherwise, and: release all parties from alll liability from any damage that may result for dismissal. any possible driver and criminal record. from furnishing same to you. Ihave read and agree to above statements. Signature Date