Emergency Medical Transport, Inc.

Emergency Dispatch Center Numbers

Toll Free Everywhere	800-739-7661
Belmont County, OH	740-635-5555 740-671-1111 740-425-9111
Carroll County, OH	330-627-0000 330-863-3333
Columbiana County, OH	330-332-3332 330-829-9900
Harrison County, OH	740-942-HELP (740-942-4357)
Mahoning County, OH	330-332-3332 330-829-9900
Marshall County, WV	740-635-5555
Ohio County, WV (Wheeling)	740-635-5555
Stark County, OH	330-832-CARE (330-832-2273) 330-829-9900 330-478-4111 330-484-4000
Summit County, OH	330-688-9111

Non-Emergency Telephone

Non-Emergency: 330-484-8894

Billing Questions: 330-484-8894 Ext 73

Mailing Address

Corporate Headquarters
2511 Waynesburg Drive SE
Canton, Ohio 44707

Online Employment Application

Basic Information

Position Applied For:
First Name:
Last Name:
Middle Name:
Address:
City:
State:
Zip Code:
Home Phone Number:
Cell and Carrier:
Pager and Carrier:
Social Security Number:
Have you filed an application with us before?	Yes No If yes, give date:
Have you been employed with us before?	Yes No If yes, give date:
Are you related to any current employee(s)?	Yes No If yes, give name(s):
If hired, are you willing to work overtime?	Yes No
Are you currently employed?	Yes No
May we contact your current employer?	Yes No
On what date would you be available for work?
Do you have a valid driver's license?	Yes No If yes, which State:
Are you prevented from being lawfully employed in this country because of Visa or Immigration Status?	Yes No
Can you provide proof of your eligibility to work?	Yes No
Are you able to perform the essential functions of the job you are applying for with or without accommodations?	Yes No
Have you been convicted of a felony in the last 7 years? (conviction will not necessarily disqualify applicant from employment)	Yes No If yes, please explain:
Have you ever been discharged from a job? (discharge will not necessarily disqualify applicant from employment)	Yes No

Education

	High School	College	Other (specify)
School name and location
Years Completed	9 10 11 12	1 2 3 4	1 2 3 4
Describe course of study
Describe any honors received

Fire and EMS related training

	Year Completed	Certification Number	Institution/Location
EMT_B
EMT_I
Paramedic
Firefighter 1A
Firefighter Other
Hazmat Level:

Describe any other specialized training or qualifications you have relating to the position applied for.
Describe any computer skills you possess, including software and hardware experience.

Previous Jobs

Job 1

Employer
Address
Phone Number
Job Title
Job Supervisor
Reason for leaving
Dates employed	From To
Salary	Starting Ending
Describe work performed
May we contact?	Yes No

If there are any employers listed above whom you do not wish to be contacted, please explain why.

References

Give name, address and telephone number of three references who are not related to you and are not previous employers.

Reference 1

Name
Address
City
Zip Code

Reference 2

Name
Address
City
Zip Code

Reference 3

Name
Address
City
Zip Code

In Case of Emergency

Name
Address
Phone Number
Relationship

Applicant's Statement

I certify that the facts contained in this application are true and complete to the best of my knowledge. I hereby authorize you to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process. I release all parties from any liability in connection with the provision and use of such information.
I understand and agree that any falsification , misrepresentation, or omission either on the employment application form or in my responses to questions asked during the interview or examination process may disqualify me from further consideration for employment, or if employed, will subject me to immediate termination whenever the falsification , misrepresentation, or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope.
I understand and agree that, if employed by this organization, I will abide by its rules and regulations which I understand are subject to change.
I understand that a physical examination and a chemical test for the presents of illegal and controlled substances may be required before the commencement of and / or during my employment. I release EMERGENCY MEDICAL TRANSPORT INC. its authorized agents, and its employees, and all others persons, companies, and other entities from any and all liabilities arising out of any physical examination or chemical testing.

I Agree

Employee Initials:

Employee DOB:

MVR Request

Insured: Emergency Medical Transport Inc.

Date
Employment Candidate
DOB
Social Security Number
DL Number
State Issued
Expires

I authorize EMT Inc and Their Current Insurance company to check my motor vehicle report for prior to hire background investigation. I understand the results of the Motor Vehicle Report may effect my employment eligibility with EMT Inc. I understand that as a condition of my employment I will also be required to undergo a background investigation check and driver's license check, and I authorize such investigations to be conducted.

I Agree

Employee Initials:

Employee DOB:

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