Employment Application
Date of Application
Position Applied For
When are you available to start?
Personal Information
Middle
First Name
Last Name
Address                                                                                    City                                                                State                        Zip
Best Phone Number to Contact You
Email
Secondary Number if Applicable
No
Yes
Nat'l Number (if applicable)
State License Number (if applicable)
Are you at least 21 years of age?
Education History- List most current first
Type of School
Name of School
Address                                                                                    City                                                                State                        Zip
Years Attended
Course of Study
Degree Obtained
Education History- Continued
Type of School
Name of School
Address                                                                                    City                                                                State                        Zip
Years Attended
Course of Study
Degree Obtained
Education History- Continued
Type of School
Name of School
Address                                                                                    City                                                                State                        Zip
Years Attended
Course of Study
Degree Obtained
Education History- Continued
Type of School
Name of School
Address                                                                                    City                                                                State                        Zip
Years Attended
Course of Study
Degree Obtained
Employment History- List most current first
Company Name
Telephone
Start Date
End Date
Address                                                                                    City                                                                State                        Zip
Reason for Leaving
Describe Work Performed
Salary
Job Title
Supervisor
Yes     No
May we contact?
Employment History- Continued
Company Name
Telephone
Start Date
End Date
Address                                                                                    City                                                                State                        Zip
Reason for Leaving
Describe Work Performed
Salary
Job Title
Supervisor
Yes     No
May we contact?
Employment History- Continued
Company Name
Telephone
Start Date
End Date
Address                                                                                    City                                                                State                        Zip
Reason for Leaving
Describe Work Performed
Salary
Job Title
Supervisor
Yes     No
May we contact?
Employment History- Continued
Company Name
Telephone
Start Date
End Date
Address                                                                                    City                                                                State                        Zip
Reason for Leaving
Describe Work Performed
Salary
Job Title
Supervisor
Yes     No
May we contact?
Additional Information
You may exclude any information which would reveal gender, race, religion, national origin, age, disability, or other protected status.
Please describe why you want to become part of our team
Please describe any specialized training, apprenticeships, skills, civic, volunteer, and extracurricular activities you feel may benefit
you in this job. List any other languages you speak, read or write in addition to English
Please describe any classes you are qualified to teach
Please describe any military experience
Have you applied to become part our team before? If so when?
Have you been part of the Miller EMS team before? If so when? Reason for leaving
Do you have any fiends or relatives who are part of the Miller EMS team? If so who?
Are you prevented from becoming lawfully employed in this country?
Can you travel of your job requires it?
Miller EMS participates in FEMA deployments. Are you willing to be
part of the disaster response team that deploys?
Have you every been convicted of a felony?
If yes please expalin
Do you have a clean driving record?
How did you learn about Miller EMS?
Please provide at least three references including name, phone number, relation, and length of relation.
Initial each agreement
I certify that the answers given herein are true and complete.


I authorize investigation of all statements made in this application.



This application shall be considered active for 60 days. Any applicant wishing to be considered for employment
beyond the time period should inquire with Miller EMS human resources department prior to the expiration date
in writing to request an extension date for another 30 days. Any information on the application must be updated
prior to the 60 day expiration period. I hereby understand and acknowledge that, unless otherwise defined by
applicable law, any employment relationship with this organization is of an "at will" nature which means the
employee may resign at any time and the employer may discharge the employee any time with or without cause.
This "at will" relationship may not be changed by written document or by conduct unless change is specifically
acknowledged in writing by the company owner/director.



I understand in the event of employment, that discovery of false or misleading information given in my application
or oral interview may result in my discharge.



I understand I am required to abide by all the rules, policies, and regulations of my employer.



I understand the bas
ic shift length in Owasso is a 12 hour shift. I may request longer shifts but they are not guaranteed.


I understand I may be employed at a Miller EMS base with a rotational weekend schedule. I understand that full time
personnel are required to take part in the rotation.


I understand nights, weekends, holidays are considered standard work days and understand that if employed I will be
expected to work the same as my schedule falls or as a rotational schedule requires.


I understand that if employed with Miller EMS I am expected to be part of their commitment to maintaining a
professional, clean, ready, team approach to the delivery of EMS services.


I understand that Miller EMS values a professional approach and cordial relationship with all other EMS and
emergency services, health-care facilities, the public, each patient, and anyone their crews come into contact with. I
agree to support and uphold this value at all times.


I understand I am required to abide by all the rules, policies, protocols, and regulations of my employer.
My electronic signature below affirms all information I provided in this application to be true and accurate to the best of my knowledge and that
I have thoroughly read and understand each portion of the application.
AN EQUAL OPPORTUNITY EMPLOYER
Federal law obligates Miller EMS to provide reasonable accomodation to the known disabilities of applicants and employees, unless to do so would pose an undue hardship. Please feel free to let
us know if you need any accomodations to complete the application process or to perform any essential elements of the position sought

Miller EMS participates in e-verify eleigibility for hie in the United States

Applicants are considered for all positions, and staff members are trwated during their time of service, without regard to race, color, religion, sex, national origin, ancestry, marital status, age,
disability, veteran status or any other prohibited basis of discrimination, as provided under applicable state and federal law.