Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Please read carefully. Omission of information except as noted, will invalidate your application from consideration.

Employment History

Employer Name*

Phone

Start Date

End Date

Job Title

Starting Pay Rate

Ending Pay Rate

Summarize the nature of the work performed and job responsibilities (200 chars left)

Immediate Supervisor & Title*

Supervisor's Phone

May we contact this employer? Yes No

Reason for leaving? (100 chars left)

#2 Employment History

Employer Name*

Phone

Start Date

End Date

Job Title

Starting Pay Rate

Ending Pay Rate

Summarize the nature of the work performed and job responsibilities (200 chars left)

Immediate Supervisor & Title*

Supervisor's Phone

May we contact this employer? Yes No

Reason for leaving? (100 chars left)

#3 Employment History

Employer Name*

Phone

Start Date

End Date

Job Title

Starting Pay Rate

Ending Pay Rate

Summarize the nature of the work performed and job responsibilities (200 chars left)

Immediate Supervisor & Title*

Supervisor's Phone

May we contact this employer? Yes No

Reason for leaving? (100 chars left)

Professional References - List at least 2 professional references.

Name of Professional Reference #1*

Phone*

Name of Professional Reference #2*

Phone*

Name of Professional Reference #3

Phone

Personal References - List at least 2 personal references, not related to you.

Name of Personal Reference #1*

Reference #1 Phone*

How do you know this person? (100 chars left)

Name of Personal Reference #2*

Reference #2 Phone*

How do you know this person? (100 chars left)

Name of Personal Reference #3

Reference #3 Phone

How do you know this person? (100 chars left)

Criminal Convictions

Have you, within the last seven years, been convicted of or plead guilty or Nolo Contendere (No Contest)?* Yes No

If Yes, state the nature of the crime(s), when and where convicted, and the dispotition of the case. Convictions that have been expunged, sealed, or legally eradicated need not be listed. A conviction will not necessarily disqualify you from employment. The nature of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for may be considered. (200 chars left)

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Please read carefully. Omission of information except as noted, will invalidate your application from consideration.

I hereby authorize Signature Ambulance to receive and share any criminal history record information, with perspective employers pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

I hereby state that the information given by me in my employment application is true and complete in all respects. I understand that in consideration of my application, an investigation may be conducted of my past employment and activities. I authorize past employers, personal references and any other persons with whom I am acquainted to answer all questions asked converning my previous employment record, ability, military service, education background, medical history, criminal record history, credit history, driving record, workers' compensation claims, character and reputation. I release all persons, including past employers, credit bureaus and government agencies, from any liabilities or damages on account of having furnished such information in good faith.

In consideration of my application, I authorize Signature Ambulance, and/or its agents to conduct such an investigation and release Signature Ambulance, including its agents, officers, employees and representatives from all liability or responsibility for this investigation. I understand that the information requested below regarding sex, race and date of birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate agaist me in violation of any law. I understand any initial employment offer will be contingent until all information is obtained and processed, including results of a urine drug test, and may be subsequently withdrawn based on the results of these investigations.

I understand that a consumer report may be requested or an investigation conducted. I further understand that if employment is denied in whole or in part because of information obtained from a consumer reporting agency, I have the right to make a written request within a reasonable period of time to receive information about the scope and nature of the investigation. A fax or a photo copy of this authorization shall be valid as the original.

Signature*

Applicant's Full Legal Name*

Maiden Name Or Any Other Name Used*

Social Security Number*

Driver's License State & Number*

Date of Birth*

Sex* Male Female

Email Address (Please note that e-mail will be the primary means of communication with you)*

Emergency Contact Name*

Relationship*

Emergency Contact Home#*

Emergency Contact Work #*

Emergency Contact Cell #*

Signature*

Date*

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Please read carefully. Omission of information except as noted, will invalidate your application from consideration.

Signature Ambulance is committed to maintaining a safe, productive work environment at all facilities and work sites and to safeguarding all property connected with such employment. Because the concern for the safety of all Signature Ambulance associates is paramount, the signing of the Drug and Alcohol Testing Consent Form, constituting agreement and cooperation with this policy, is required of all persons as a condition of employment by Signature Ambulance.

It is the policy of Signature Ambulance not to retain any individuals who test positive for any illegal drug in their system or use illegal drugs or controlled substances, in any amount, regardless of frequency, without a medically acceptable prescription. Therefore, to rule out the presence of non-prescribed or prohibited dangerous substances in the body, Signature Ambulance associates may, consistent with state law, be required to undergo a drug screening test for any or all of the following reasons:

Pre-employment purposes
Continuation of employment
Periodic, announced (routine) testing
Randomly to ensure consistency and continuance of policy
For cause due to reasonable suspicion by Signature Ambulance or its clients
Post-accident (work-related injury)

In addition, Signature Ambulance associates may be required to undergo alcohol screening when there is suspicioun of impairment or a critical event (work-related injury, unusual behavior, etc.).

I understand that according to signature Ambulance policy, I may be required to sibmit a sample of my urine and/or other body fluids, tissue or filaments for chemical analysis. I understand that qualified personnel will perform the analysis.

I consent freely and voluntarily to this request for a specimen of urine and/or other body fluids, tissues or filaments. I hereby and herewith release Signature Ambulance, the medical provider obtaining the samples and the laboratory performing the analysis (including its employees, agents and contractors) are not liable whatsoever arising from this request to furnish my urine and/or other body fluids, tissues or filaments, the testing of the sample and decision made concerning my employment based upon the results of the analysis.

I understand that any person refusing to take or failing to pass the drug-screening test will not be qualified for employment with Signature Ambulance until a negative drug test result can be obtained. Initial testing and confirming tests for positive results are at the expense of Signature Ambulance. Retesting is at my expense, consistent with state law.

I have read the foregoing policy statement and consent form and understand and agree to submit to drug and alcohol testing as part of the terms and conditions of my employment with Signature Ambulance.

Signature*

Social Security Number*

Print Name*

Date*

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Please read carefully. Omission of information except as noted, will invalidate your application from consideration.

Please Initial

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of time elapsed before discovery.

I hereby authorize Signature Ambulance to thoroughly investigate my references, work record, education, personal and professional references and other matters related to my suitability for employment. Further, I authorize the references I have listed to disclose to SIgnature Ambulance all letters, reports, and other information related to my work records, without given me prior notice of such disclosure. In addition, I hereby release Signature Ambulance, my former employers and other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.*

I understand that nothing contained in the application or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between Signature Ambulance and me. In addition, I understand and agree that if I am employed, my employment is at will and is for no definite or determinable period and may be terminated at any time, with or without prior notice, or with or without cause, at the option of either myself or Signature Ambulance, and that no promises or representations contrary to the foregoing are binding on Signature Ambulance unless made in writing and signed by me and Signature Ambulance designated representative.*

I understand that, in connection with my application for employment, Signature Ambulance may obtain a consumer report and/or investigate consumer reports about me that may contain information as to my character, general reputation, personal characteristics and mode of living. Such reports may include or consist of my driving history obtained from the Georgia Department of Motor Vehicles. I further understand that any job offer extended by Signature Ambulance is contingent upon receipt of a favorable consumer or investigative consumer report about me.*

I understand that, in connection with my application for employment, depending upon the position for which I have applied, any offer of employment is conditioned upon my taking and passing a pre-employment drug test and, if necessary for the position for which I have applied, a pre-employment medical examination and/or physical agility test. I understand that I may refuse to take any required pre-employment drug test or medical examination but, that if I do, any offer of employment will be immediately withdrawn.*

Signature of Applicant:*

Name*

Date

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Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Signature Ambulance at Statesboro, LLC

APPLICATION FOR EMPLOYMENT

Signature Ambulance

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