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