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Medexpress Ambulance Service, Inc.
Section A: Personal Data
Email Address*
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Enter Email Confirm Email

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Name*
First Middle Last Suffix
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
You are:*
- Under the age of 18
- Over the age of 18 but younger than 23
- 23 years or older

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Section B: Desired Position
Desired Status*
- Full Time
- Part Time/PRN
- Disaster Response Only
Desired Position*

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Section C: State and National Licenses
Do you have a valid driver's license?*
- Yes
- No
State*
Driver's License Number*
Do you hold a National Registry license?*
- Yes
- No
National Registry Level
- EMT-Basic
- EMT-Advanced
- EMT-Paramedic
National Registry Number*
Are you Licensed to work on an ambulance in Louisiana?*
- Yes
- No
What 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 Responder
- EMT-Basic
- EMT-Advanced
- EMT-Paramedic
Louisiana License Number*

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Do you hold a license that allows you to work on an ambulance in any other states?*
- Yes
- No
What 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 Responder
- EMT-Basic
- EMT-Advanced
- EMT-Paramedic
Alaska License Number*
Nevada License Level*
- Emergency Medical Responder
- EMT-Basic
- EMT-Advanced
- EMT-Paramedic
Nevada License Number*
New Jersey License Level*
- Emergency Medical Responder
- EMT-Basic
- EMT-Advanced
- EMT-Paramedic
New Jersey License Number*

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Section D: Education
Formal 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 Name Course of Study Graduate (Y/N) Year and Degree Zip Code

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Section E: Work History
Work 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.
Employer City Zip Phone Supervisor Job Title Start & End Date

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Section F: Specialized Skills
Do 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 Experience
Total years of commercial driving experience for each class.
Class A Class B Class C Class D

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Section G: Additional Information
Do 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?*
- Yes
- No
Who did you speak to about this position?*

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Section H: Attachments & Resumes
Attachments
Please 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 Uploads
Size Limit: 128MB
Drop files here or

Accepted file types: jpeg, jpg, png, pdf, doc, docx, rtf.

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Do you wish to upload a copy of your resume?*
- Yes
- No
Resume Upload*
Size Limit: 128MB.
Accepted file types: pdf, doc, docx, rtf.

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Signature
Medexpress 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*
Phone
This field is for validation purposes and should be left unchanged.

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