Lincoln Emergency Medical Services

1. Company*

Phone Number*

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From:

Month Day Year

To:

Month Day Year

Reason for Leaving

May we contact your previous Supervisor for a reference?

Yes No

2. Company*

Phone Number*

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From:

Month Day Year

To:

Month Day Year

Reason for Leaving

May we contact your previous Supervisor for a reference?

Yes No

State:

Certification Number:

NREMT Number:

Expiration Date:

Month Day Year

Check all that apply:

CPR ITLS ACLS PEPP EVOC AMLS PHTLS

Disclaimer:

�I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I understand that I must submit to a pre-employment and random drug and alcohol screening and failure to successfully pass such test will result in automatic dismissal of my application and/or termination of my employment. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing,
                        unless it is in writing and signed by an authorized company representative.

Referred to Lincoln EMS?

Signature:*

Digital Signature

Date:*

Month Day Year

LINCOLN EMS

EMS Certification

Current Certifications

Disclaimer and Signature