Employment Application Name*Present Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Contact Number*Position Applied For?*EMT (Emergency Medical Technician)AEMT (Advanced Emergency Medical Technician)Paramedic (or PHRN)Physician (PH)ClericalEMS CaptainField Training Officer (FTO)Physician Assistant (PH)Employment Type Desired?*Part TimeFull TimeFull or Part TimeVolunteerAre are able to work? (Select all that Apply)8 Hour Shifts12/13 Hour Shifts16 Hour Shifts24 Hour ShiftsNightsWeekendsHold 'control' button to select multiple enteries.Date You Can Start MM slash DD slash YYYY Are you 21 years or older?*YesNoAre you 18 years or older? Yes No Have you worked for STEMS before?*NoYesIn what position were you employed?EMTParamedicTransport AssociateDo you have a Valid and Unrestricted PA Driver's License*YesNoOut of StateHave you ever been convicted of a Felony?*NoYesIf yes, please provide an explanationA "yes" answer will not automatically disqualify you from employment. The nature of the offense, date, and the job you are applying for will also be considered.Are you now or do you expect to be engaged in any other business or employment?YesNoPlease ExplainEducation Record:Highest Level of Education Achieved:Highschool/GEDSome CollegeAssociate's DegreeBachelor's DegreeGraduate DegreeDiploma/DegreeBusiness or Technical SchoolCollege / Graduate SchoolWork History (Your last three jobs, begining with the most recent)EmployerStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ManagerPhone NumberYour title/dutiesEnding wageReason for leavingEmployer (2)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ManagerPhone NumberYour title/dutiesEnding wageReason for leavingEmployer (3)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ManagerPhone NumberYour title/dutiesEnding wageReason for leavingProfessional ReferencesReference (1)PhoneContact's Email Relationship to youReference (2)PhoneContact's Email Relationship to youReference (3)PhoneContact's Email Relationship to youHow did you hear about STEMS?Professional ReferenceOur websiteFacebookTwitterLinkedinIndeedOtherCertifications/LicensesCurrently Certified in PA as:*EMR (Emergency Medical Responder)EMT (Emergency Medical Technician)AEMT (Advanced Emergency Medical Technician)ParamedicPHRN (Pre-hospital Registered Nurse)NoneInitial Certification Date: MM slash DD slash YYYY Certification Expiration:* MM slash DD slash YYYY Current Professional Certifications (Check all that Apply)BLS - CPREVOC/EVDT/EMSVOACLS (Advanced Cardiac Life Support)PALS (Pediatric Advanced Life Support)ITLS (International Trauma Life Support)NREMT (Current)PEPP or PEARSHazmat AwarenessHazmat OperationsHazmat TechnicianHold 'control' button to select multiple entries.Please read carefully and sign. I authorize the investigation of any or all statements contained in this application and authorize any person, school current employer (except as noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I authorize the investigation of all statements contained in the application including criminal and driver's license record. I understand that failure to maintain certifications(s) or license(s) agreed to as conditions of employment may result in my termination. I understand that the employer may request an investigative consumer report from a consumer reporting agency. I understand that I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so I may obtain a complete disclosure of the nature and scope of the investigation. I have been provided with a job description for the position in which I am applying and I have read and fully understand the essential job duties and requirements. Iam able to perform all the essential functions of the position as described in the Position Description. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination . I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that if I am selected for a position dealing directly with patients, I may be required to successfully pass a drug screening examination and submit my PA PSP, PA Child Abuse and FBI background checks. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required. (Note, Susquehanna Township EMS is required by contract and regulation to perfom criminal background checks and drug screening). I certify that all information contained in this employment application is true and complete to the best of my knowledge. I understand that any false information or omissions may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.PSP ClearanceMax. file size: 2 MB. STEMS Can not accept "Volunteer" background clearancesFBI ClearanceMax. file size: 2 MB. STEMS Can not accept "Volunteer" background clearancesChild Abuse ClearanceMax. file size: 2 MB. STEMS Can not accept "Volunteer" background clearancesResumeMax. file size: 2 MB. Signature*Date MM slash DD slash YYYY CAPTCHAPlease be aware, If you receive a "Bad Gateway" Error after submission, your Application was Still received. Your may call to confirm at our Office during normal business hours. thank you Δ