Robinaugh Emergency Medical Services | Emergency and non-emergency transportation provider for Logan, Union, Hardin and Champaign counties

Personal Information

First Name

Middle Name

Last Name

Social Security Number

Email

Street Address

City

State

Zip Code

Home Phone

Other Phone

Are you at least 18 years old?

Hours Requested

Date available to start

How did you find out about this position?

Please list any relatives or friends working/volunteering here.

Position Information

Position applying for

Have you ever worked/volunteered for this organization?

Certification Information

List only current certifications. Photocopies will be required at interview.

CPR

Certification Number

Expiration Date

Certifying Agency

EMT

Certification Number

Expiration Date

Certifying Agency

EMT-P

Certification Number

Expiration Date

Certifying Agency

National Registry

Certification Number

Expiration Date

Certifying Agency

PALS

Certification Number

Expiration Date

Certifying Agency

ACLS

Certification Number

Expiration Date

Certifying Agency

BTLS

Certification Number

Expiration Date

Certifying Agency

EMD

Certification Number

Expiration Date

Certifying Agency

CDL

Certification Number

Expiration Date

Certifying Agency

Other

Certification Number

Expiration Date

Certifying Agency

Description of Other (if applicable)

Work Requirements & General Info

Can you provide proof, if hired, that you are eligible to work in the U.S.?

Yes

No

Do you have a valid driver's license?

Yes

No

Do you have any moving violations (convictions), accidents, or suspensions or revocations of your license in the last five years?

Yes

No

Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended?

Yes

No

Have you ever been excluded, or are you currently excluded, from participating in any federal health program, such as Medicare or Medicaid?

Yes

No

Have you been a resident of Ohio for more than 5 years?

Yes

No

Employment History

List your last three employers or volunteer activities, starting with the most recent.

Employer 1

Employer Name

Job Title

Supervisor

Start Date

Start Salary

End Date

End Salary

Job Description (including duties and responsibilities)

Employer Phone

Can we contact this employer?

Yes

No

Reason for Leaving

Employer 2

Employer Name

Job Title

Supervisor

Start Date

Start Salary

End Date

End Salary

Job Description (including duties and responsibilities)

Employer Phone

Can we contact this employer?

Yes

No

Reason for Leaving

Employer 3

Employer Name

Job Title

Supervisor

Start Date

Start Salary

End Date

End Salary

Job Description (including duties and responsibilities)

Employer Phone

Can we contact this employer?

Yes

No

Reason for Leaving

Military (if applicable)

Branch of Service

Start Date

End Date

Rank and Duties

Discharge Date

Location

Please explain any gaps in employment

Past Employment

Have you ever been:

Disciplined for reckless driving

Yes

No

Disciplined for excessive absenteeism

Yes

No

Disciplined for insubordination

Yes

No

Disciplined for safety violations

Yes

No

Disciplined for assault or fighting

Yes

No

Disciplined for harassment

Yes

No

Disciplined for patient abuse

Yes

No

Disciplined for alcohol or drug activity

Yes

No

Please provide details about any disciplinary actions

Answers of Yes for any of the above questions will not necessarily disqualify you from employment.

References

List three persons, other than relatives, who have knowledge of your work experience and/or education.

Professional Reference 1

Name

Occupation

Address

Years Known

Daytime Phone Number

Professional Reference 2

Name

Occupation

Address

Years Known

Daytime Phone Number

Professional Reference 3

Name

Occupation

Address

Years Known

Daytime Phone Number

List two personal references that have known you for at least three years outside work.

Personal Reference 1

Name

How they know you

Address

Years Known

Daytime Phone Number

Personal Reference 2

Name

How they know you

Address

Years Known

Daytime Phone Number

Acknowledgment

I certify that the information I have given on this application is true, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate the Company in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be "at will" and either I or the Company is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment.

If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties.

I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by the Company as a condition of my employment, and I hereby give my consent to the release of all information which the Company deems necessary to determine my ability to perform job duties now or in the future.

I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from this Company.

I hereby authorize the Company to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release the Company and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished.

I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded, my employment with the Company may be terminated.

I acknowledge that I have read and understand the above statements and agree to the terms.

Once you submit this application, it will be reviewed by our hiring team. Thank you for your interest in joining Robinaugh EMS!

Online Application

Personal Information

Position Information

Certification Information

CPR

EMT

EMT-P

National Registry

PALS

ACLS

BTLS

EMD

CDL

Other

Work Requirements & General Info

Employment History

Employer 1

Employer 2

Employer 3

Military (if applicable)

Past Employment

Education & Training

High school

College

Technical school

Other

References

Professional Reference 1

Professional Reference 2

Professional Reference 3

Personal Reference 1

Personal Reference 2

Acknowledgment