Application

Social Security Number :  (ex: xxx-xx-xxxx)
First Name : 
Middle Initial : 
Last Name : 
Street Address: : 
City : 
State : 
ZIP : 
Home Phone Number :  (ex: xxx-xxx-xxxx)
Mobile Phone Number :  (ex: xxx-xxx-xxxx)
Best Time to Call :  AM      PM
E-mail Address : 
Position Applied for : 
Preferred Schedule :         Full/Part Time  
Are you Legally Authorized to Work in the U.S.? :  Yes       No
Are you willing to relocate? :  Yes       No
When are you available to start work? :  (ex: mm/dd/yyyy)
Have you ever applied with Haynes before? :Yes    No  If Yes, When? (ex: mm/dd/yyyy)

Have you ever worked with Haynes before?

 :Yes    No      If Yes, When? Position:
   
Do you have any relatives employed with Haynes? :Yes    No      If Yes, Who?
How were you referred to Haynes? : 
Name of Haynes Employee Referred By : 
Have you ever been convicted of a crime? :Yes    No     If Yes, Explain:  

Note: A conviction does not mean you are not eligible for employment with our company. As part of screening process, Haynes Ambulance will investigate the content of this application. Honesty matters.

 

CERTIFICATE & LICENSES: (Enter all that apply)
Driver's License Number :       State:      Exp Date:
National Registry Number :       Exp Date: Type: EMT-B    EMT-I     EMT-P
State Registry Number :   State:  Exp Date: Type: EMT-B EMT-I EMT-P

 Other EMS Related Certifications  

 

EDUCATION:  
High School Info:  
Name of School Attended :  
City :  
State :  
Type of Educational Facility :  
  :  
Did You Graduate? :   Yes      No
Degree Earned :  
   
Name of School Attended :  
City :  
State :  
Type of Educational Facility :  
Major Subject :  
Did You Graduate? :   Yes      No
Degree Earned :  
   
Name of School Attended :  
City :  
State :  
Type of Educational Facility :  
Major Subject :  
Did You Graduate? :   Yes      No
Degree Earned : 

 

EMPLOYMENT HISTORY (Please list all of your employers starting with the most recent employment)
   
Company 1:  
Name Of Company :  
Address :  
City :  
State :  
ZIP :  
Phone Number :   (ex: xxx-xxx-xxxx)
From Date :  
To Date :  
Position Held :  
Beginning Salary :  
Ending Salary :  
Duties :  
Name of Supervisor :  
May We Contact :   Yes      No
Reason for Leaving :  
   
Company 2:  
Name Of Company :  
Address :  
City :  
State :  
ZIP :  
Phone Number :   (ex: xxx-xxx-xxxx)
From Date :  
To Date :  
Position Held :  
Beginning Salary :  
Ending Salary :  
Duties :  
Name of Supervisor :  
May We Contact :   Yes      No
Reason for Leaving :  
   
Company 3:  
Name Of Company :  
Address :  
City :  
State :  
ZIP :  
Phone Number :   (ex: xxx-xxx-xxxx)
From Date :  
To Date :  
Position Held :  
Beginning Salary :  
Ending Salary :  
Duties :  
Name of Supervisor :  
May We Contact :   Yes      No
Reason for Leaving

: 

 

NOTIFICATION & AGREEMENT
Please read before submitting your application.

BY SUBMITTING THIS APPLICATION, I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT ANY FALSIFICATION, MISREPRESENTATION OR OMISSION ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

THIS APPLICATION WILL BE GIVEN EVERY CONSIDERATION, BUT ITS RECEIPT DOES NOT IMPLY THAT THE APPLICANT WILL BE EMPLOYED.

IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES AND APPLICANTS FOR EMPLOYMENT BE GIVEN EQUAL OPPORTUNITY WITHOUT REGARD TO AGE, RACE, RELIGION, COLOR, SEX, NATIONAL ORIGIN, MARITAL STATUS, EXPUNGED JUVENILE RECORDS, OR PREGNANCY. IN ADDITION, OUR COMPANY GRANTS EQUAL OPPORTUNITIES TO ALL DISABLED VETERANS, VETERANS OF THE VIETNAM ERA, INDIVIDUALS WITH A DISABILITY AND/OR ANY OTHER PROTECTED CHARACTERISTICS AS IDENTIFIED BY FEDERAL, STATE, AND LOCAL LAWS.

I FURTHER UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS CONDITIONED ON THE COMPLETION OF PRE-EMPLOYMENT TESTING AND DOCUMENTATION. ALL INFORMATION IN THIS APPLICATION WILL BE INVESTIGATED. MY SUBMISSION OF THIS APPLICATION INDICATES MY AGREEMENT TO, UPON REQUEST, SIGN ALL NECESSARY CONSENT FORMS AUTHORIZING SUCH TESTS AND INVESTIGATIONS. I RELEASE FROM ALL LIABILITY ANYONE SUPPLYING SUCH INFORMATION, AND I ALSO RELEASE THE EMPLOYER FROM ALL LIABILITY THAT MIGHT RESULT FROM MAKING AN INVESTIGATION.

IF HIRED, I AGREE TO ABIDE BY ALL THE COMPANY RULES AND REGULATIONS, AND UNDERSTAND THAT, IF EMPLOYED, I AM EMPLOYED AT WILL AND THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF THE COMPANY OR ME. I FURTHER UNDERSTAND THAT NO REPRESENTATION, WHETHER ORAL OR WRITTEN BY ANY AGENT OF THE COMPANY, AT ANY TIME, CAN CONSTITUTE A CONTRACT OF EMPLOYMENT. I UNDERSTAND THAT THE COMPANY AND ALL PLAN ADMINISTRATORS SHALL HAVE THE MAXIMUM DESCRETION PERMITTED BY LAW TO ADMINISTER, INTERPRET, MODIFY, DISCONTINUE, ENHANCE, OR OTHERWISE CHANGE ALL POLICIES, PROCEDURES BENEFITS, OR OTHER TERMS OR CONDITIONS OF EMPLOYMENT.

BY USING THE “SUBMIT” BUTTON BELOW (AND SIGNING BELOW), I AM SUBMITTING MY APPLICATION FOR EMPLOYMENT TO HAYNES AMBULANCE AND ITS DIVISIONS; AND I AM ACKNOWLEDGING THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS, AND AGREE TO ALL ITEMS OUTLINED ABOVE.

 

 

SIGNATURE:           DATE:

 

 

Print off completed form and either fax it to (334) 241-5280, or drop it off in person to 2530 East 5th Street, Montgomery AL 36107.