EMS EMPLOYMENT APPLICATION - 1st Response Medical Services

1st Response Medical Services

Thank you for your interest in working for 1st Response Medical Services. Below is a brief form which is for informational use only. In order to provide patient care as an EMT or Paramedic for 1st Response Medical Services, we collect minimal information PLEASE BE SURE TO READ THE TERMS OF SERVICE PRIOR TO COMPLETING and SUBMITTING THIS APPLICATION.

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth *

Social Security Number *

Email Address *

Cell Phone Number *

Is there anything that would cause an Issue with you working for 1st Response Medical Services. (Exp... Medical, Mental, Handicap etc....) *YesNo

If yes, please explain

Are you over the age of 18? *YesNo

Medical Providor Questions

Are you a PA State Certified EMT or Paramedic? *YesNoMUST BE PA STATE CERTIFIED EVEN IF YOU HAVE NATIONAL REGISTRY

What is your Professional Provider level? *EMTAEMTPARAMEDICcertification level

CERTIFICATION # *

MANDITORY QUESTIONS

DO YOU HAVE YOUR OWN VEHICLE/RELIABLE TRANSPORTATION?? *Please note that Public Transportation is not reliable transportation. if you do not have a vehicle, you will be unable to work with us!

Do you have at Minimum, and BLS CPR Certification or Equivalent? *

CURRENT CERTIFICATIONS

Please Upload a Copy of your EMT/AEMT/MEDIC Certification, BLS, ACLA, PALS, PHTLS, EVDT, or any other documents you would like to include. iF THE UPLOAD WILL NOT WORK, PLEASE SUBMIT COPES TO APPLY@PGHSAFETY.COM. APPLICATIONS WITH NO COPIES OF CERTIFICATIONS WILL NOT BE ACCCEPTED!

Agreement

I certify that information contained in this application is true and complete. I certify that I have read, and accept the NON-COMPETE Agreement. I understand that false information may be grounds for denial of Healthcare Provider status. I also understand that as a medical professional, I am expected to operate professionally and operate according to my current medical certification level. I understand that I will be an employee of 1st Response Medical Services providing services equal to my scope of practice as per my certification..

Do you agree to the 1st Response Medical Services non-compete agreement? *Yes, I agree with the 1st Response Medical Services Non-Compete Agreement.

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