Step 1 of 12 8% Medexpress Ambulance Service, Inc.Section A: Personal DataEmail Address*Let's get started with your email address! Enter Email Confirm Email Save and Continue Later Name* First Middle Last Suffix Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country United StatesAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe You are:*Under the age of 18Over the age of 18 but younger than 2323 years or older Save and Continue Later Section B: Desired PositionDesired Status* Full Time Part Time/PRN Disaster Response Only Desired Position*Select PositionEmergency Medical ResponderEMT-BasicEMT-AdvancedEMT-ParamedicMedTrans DriverDispatcherMechanicAdministration/ManagementEducationOther/Not Listed Save and Continue Later Section C: State and National LicensesDo you have a valid driver's license?*YesNoState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License Number*Do you hold a National Registry license?*YesNoNational Registry LevelEMT-BasicEMT-AdvancedEMT-ParamedicNational Registry Number*Are you Licensed to work on an ambulance in Louisiana?*YesNoWhat States are you licensed in?* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming None of the Above Louisiana License Level*Emergency Medical ResponderEMT-BasicEMT-AdvancedEMT-ParamedicLouisiana License Number* Save and Continue Later Do you hold a license that allows you to work on an ambulance in any other states?*YesNoWhat other states are you licensed to work on an ambulance?* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alaska License Level*Emergency Medical ResponderEMT-BasicEMT-AdvancedEMT-ParamedicAlaska License Number*Nevada License Level*Emergency Medical ResponderEMT-BasicEMT-AdvancedEMT-ParamedicNevada License Number*New Jersey License Level*Emergency Medical ResponderEMT-BasicEMT-AdvancedEMT-ParamedicNew Jersey License Number* Save and Continue Later Section D: EducationFormal Educational Information*List each formal educational institution that you have attended. Start with your High School and work toward the most recent. You may list up to ten. Click the + button to add a new row. School or College NameCourse of StudyGraduate (Y/N)Year and DegreeZip Code Save and Continue Later Section E: Work HistoryWork History*List each place of employment that you have held (NOT including self-employment). Please begin with the oldest and work toward the most recent. You may list up to ten. Click the + button to add a new row.EmployerCityZipPhoneSupervisorJob TitleStart & End Date Save and Continue Later Section F: Specialized SkillsDo you hold any of the following? ACLS PHTLS PALS Other List other:*Are you an instructor for any of the following? CPR/AED ACLS PHTLS PALS Emergency Medical Responder EMT-Basic EMT-Advanced EMT-Paramedic Other List Other:*Commercial Driving ExperienceTotal years of commercial driving experience for each class.Class AClass BClass CClass D Save and Continue Later Section G: Additional InformationDo you have any schedule limitations?*On what date would you be available to begin work?* Date Format: MM slash DD slash YYYY Has this position been previously discussed with you by a Management Representative?*YesNoWho did you speak to about this position?* Save and Continue Later Section H: Attachments & ResumesAttachmentsPlease provide copies of all that apply: Class D Drivers License State Registry Card Defensive Driving Certs PALS Social Security Card AHA BCLS "C" Card Hazmat Certifications PHTLS National Registry Card AHA ACLS Card Board of Examiners Certificate MVR Certification UploadsSize Limit: 128MB Drop files here or Accepted file types: jpeg, jpg, png, pdf, doc, docx, rtf. Save and Continue Later Do you wish to upload a copy of your resume?*YesNoResume Upload*Size Limit: 128MB.Accepted file types: pdf, doc, docx, rtf. Save and Continue Later SignatureMedexpress Ambulance Service is an Equal Opportunity Employer. We consider applicants without regard for race, color, religion, creed, sex, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities. I consent to take the physical examination, and such future physical examinations as may be by this institution at such times and places as the institution shall designate. I agree to take a pre-employment drug test and will participate in future random drug screening as by this institution. Any questions or comments, please contact the Director of Human Resources at 1-800-259-9771 NOTE: The completion of this form is a request for employment information but is not an application for employment.By signing below, I confirm that the information contained above is true and correct to the best of my knowledge.Application Signature*NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.