Doctor's Ambulance Service has been providing Emergency Medical Transportation to Orange County since 1974.

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APPLICANT INFORMATION

Full Name:
E-mail:
Present Address:
How long have you lived there?
Home Phone:
Cell Phone / Pager:
Previous Address:

EMERGENCY CONTACT INFORMATION

Name:
Phone Number:
Relationship:

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national orgin, age, martial or veteran status, or the presence of a non-job related medical condition or hardship.

AVAILABILITY

Date Available:
Position Applying For:
How did you hear about us?
What type of work are you looking for?		Full Time Part Time
Are you 18 years of age or older?		Yes No
Have you ever worked for this company?		Yes No
If yes give dates and position:
Do you have friends or family working here?		Yes No
Do you have a reliable means of transportation to travel to and from work, which wil allow you to consistently arrive at work on time?		Yes No

PERSONAL HISTORY STATEMENT

Have you been cited for a traffic violation of any kind within the last FIVE years?
If you have served in the military or reserves what revelant skills have you aquired?
NOTE: An affirmative answer to the following question will not automatically disqualify you from consideration for the position for which you are applying. Factors such as age of the conviction, time of events, seriousness and nature of the violation, and rehabilitation are taken into account.
Have you ever pled guilty or 'no contest' or been conviceed of a crime?		Yes No
If Yes, please give date and details of each:

EDUCATION

School	Name & Address	Number of Years Completed	Did you Graduate?	Degree or Diploma?
High School
College
Vocational / Business School
Health Care

EMPLOYMENT HISTORY

Employer #1:		Telephone Number
Address:		Dates of Employment:
Type of Business:		Starting Hourly Rate:
Supervisor:		Final Hourly Rate:
Reason for Leaving		Job Title
Description of Work Preformed:
May we contact this employer for a reference?

Employer #2:		Telephone Number
Address:		Dates of Employment:
Type of Business:		Starting Hourly Rate:
Supervisor:		Final Hourly Rate:
Reason for Leaving		Job Title
Description of Work Preformed:
May we contact this employer for a reference?

Employer #3:		Telephone Number
Address:		Dates of Employment:
Type of Business:		Starting Hourly Rate:
Supervisor:		Final Hourly Rate:
Reason for Leaving		Job Title
Description of Work Preformed:
May we contact this employer for a reference?

Have you ever been terminated or asked to resign from any job? Yes No

Please explain fully any gaps in your employment history.

May we contact your current employer for a reference?

CHARACTER REFERENCES

Name:
Phone Number:
Address:
Occupation:
Years Known:

Name:
Phone Number:
Address:
Occupation:
Years Known:

Name:
Phone Number:
Address:
Occupation:
Years Known:

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE,

TYPE YOUR FULL NAME:
TODAY'S DATE: