Application | Susquehanna Township EMS

Name*

Present Address

Street Address City State ZIP Code

Email*

Contact Number*

Position Applied For?*

Employment Type Desired?*

Are are able to work? (Select all that Apply)

Hold 'control' button to select multiple enteries.

Date You Can Start

Are you 21 years or more?*

Are you 18 years or older?

Yes
No

Have you worked for STEMS before?*

In what position were you employed?

Do you have a Valid and Unrestricted PA Driver's License*

Have you ever been convicted of a Felony?*

If yes, please provide an explanation

A "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?

Please Explain

Education Record:

Highest Level of Education Achieved:

Diploma/Degree

Business or Technical School

College / Graduate School

Work History (Your last three jobs, begining with the most recent)

Employer

Start Date

End Date

Address

Street Address City State ZIP Code

Manager

Phone Number

Your title/duties

Ending wage

Reason for leaving

Employer (2)

Start Date

End Date

Address

Street Address City State ZIP Code

Manager

Phone Number

Your title/duties

Ending wage

Reason for leaving

Employer (3)

Start Date

End Date

Address

Street Address City State ZIP Code

Manager

Phone Number

Your title/duties

Ending wage

Reason for leaving

Professional References

Reference (1)

Phone

Contact's Email

Relationship to you

Reference (2)

Phone

Contact's Email

Relationship to you

Reference (3)

Phone

Contact's Email

Relationship to you

Certifications/Licenses

Currently Certified in PA as:*

Initial Certification Date:

Certification Expiration:*

Current Professional Certifications (Check all that Apply)

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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.

I

am 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.

Upload Background Clearances (FBI, PSP, Child Abuse)

Drop files here or

STEMS Can not accept "Volunteer" background clearances

Signature*

Date

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Please 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

STEMS Employment Application

Employment Application

Education Record:

Work History (Your last three jobs, begining with the most recent)

Professional References

Certifications/Licenses