Personal Information

Have you previously been employed at ATC? * Yes No

If Yes, provide dates of employment, location and reason for separation from employment. From:

To:

General Information

Position Applying For: * Paramedic EMT

Type of employment desired: * Full Time Part Time

Preferred Location: * Merrillville, IN Indianapolis, IN

Are you eligible to work in the United States? * Yes No

Do you have a valid driver's license? * Yes No

License No: State: Select State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Expiration Date:

Prefered method on contact: * Phone Email Text Messaging / SMS When are you available to start? *

EMS Credentials

Level of EMS Certificate: * EMT-B EMT-Paramedic

PSID Number Expiration Date:

CPR Card Number Expiration Date:

Work Experience

Employer Name: * Job Title: * Type of Business: *

Duties: * Dates Employed From: * To:

Supervisors Name: * Telephone: * May we contact your supervisor? * Yes No



Reason for leaving: *

Work Experience

Employer Name: Job Title: Type of Business:

Duties: Dates Employed From: To:

Supervisors Name: Telephone: May we contact your supervisor? Yes No



Reason for leaving: