Basic Details Qualifications and Education Employment History Terms and Conditions Name County of Residence Are you 18 or older? * Yes No Are you 21 or older? * Yes No First Name Middle Name Last Name Social Security Number Street Address City State Zip Code Email Primary Phone Secondary Phone Referral Source * Mobile EMS Website Advertisement Relative Employee Other Position Applied For * Do you have a valid Alabama State EMS License? * Yes No Minimum Pay Acceptable * Pay Per * Hour Month Year Full or Part Time * Full-Time Part-Time Either Do you have a valid drivers license? * Yes No Date Available * Are you eligible to work in the United States?? * Yes No Have you ever been convicted of a felony? * Yes No Have you ever been employed by Mobile County Emergency Medical Services System, Inc.? * Yes No Please list any relatives currently employed by Mobile County Emergency Medical Services System, Inc. and state their relationship. Driver's license number, if driving is an essential job function Drivers License State Date Available for Work * Are you a Veteran of any war, campaign, or expedition? * Yes No Are you a Vietnam-era Veteran? * Yes No Are you a Special Disabled Veteran * Yes No What is your desired salary range? * All jobs require the following physical requirements: Be able to lift 50lbs Be able to stand, bend, stoop, squat, or kneel regularly Be able to climb stairs and ladders Are you able to meet these Physical Requirements? * Yes No Qualifications/Certifications For Issuer, please indicated Agency, State, or Instructor EMT Expiration Date CPR Expiration Date ACLS Expiration Date BTLS Expiration Date PALS Expiration Date EMT Level CPR Level ACLS Level BTLS Level PALS Level EMT License Number CPR License Number ACLS License Number BTLS License Number PALS License Number EMT Issuer CPR Issuer ACLS Issuer BTLS Issuer PALS Issuer Other Certification Name 1 Other Certification Name 2 Other 1 Expiration Date Other 2 Expiration Date Other 1 Level Other 2 Level Other 1 License Number Other 2 License Number Other 1 Issuer Other 2 Issuer Education History Name of High School High School Address High School Course of Study High School Highest Grade Completed High School Phone High School Start Date High School End Date Name of Current or Most Recent College or University School 2 Address School 2 Course of Study School 2 Credit Hours Earned School 2 Phone School 2 Start Date School 2 End Date Name of Next Previous College or University School 3 Address School 3 Course of Study School 3 Credit Hours Earned School 3 Phone School 3 Start Date School 3 End Date Name of Next Previous College or University School 4 Address School 4 Course of Study School 4 Credit Hours Earned School 4 Phone School 4 Start Date School 4 End Date Employment History Name of Present or Last Employer Employer 1 Address Employer 1 Duties and Responsibilities Employer 1 Job Title Employer 1 Average Hours Worked Per Week Employer 1 Reason for Leaving Employer 1 Phone Employer 1 Start Date * Employer 1 End Date * Employer 2 Name Employer 2 Address Employer 2 Summary of Work Employer 2 Job Title Employer 2 Average Hours Worked Per Week Employer 2 Reason for Leaving Employer 2 Phone Employer 2 Start Date Employer 2 End Date Employer 3 Name Employer 3 Address Employer 3 Summary of Work Employer 3 Job Title Employer 3 Average Hours Worked Per Week Employer 3 Reason for Leaving Employer 3 Phone Employer 3 Start Date Employer 3 End Date If you have a resume or other documentation you would like to upload: Only .pdf, .doc, .docx, .txt files allowed I agree to read the following terms and conditions Yes