In the box below please indicate position (s) applying for:
Full time
Part time
Desired salary
Best time to contact you
Minimum hours wanted
Available start date
Personal information
Last name
First name
M.I.
Home address,City, State, Zip
Mailing address, City, State, Zip
Email address
Best number to reach you at
Driver license state
Driver license #
SSN#
OK medic lic. #
NREMT #
Are you at least 18?
Emergency contact name and phone number. You may list up to three
Are there any allergies or medical information you would like us to know of?
Education history. List most current first
Use one space per school. List name of school, type of school, dates attended, course of study and
degree obtained. List only one school per box provided. List up to four.
Employment history. List most current first
Use one space per job. List name of company, contact phone number, dates employed, name of
supervisor, job title, salary, and work your performed.
List only one school per box provided. List up to four.
Yes
May we contact this employer?
No
Yes
No
May we contact this employer?
Yes
No
May we contact this employer?
Yes
No
May we contact this employer?
Additional information. You may exclude information that would reveal gender, race,
religion, national origin, age, disability, or other protected status.
Please describe why you want to work for Miller EMS.
Please describe any specialized training, apprenticeship, skills, civic, volunteer, and
extracurricular activities you feel may benefit you in this job. List any other languages
other than English you can speak, read, or write.
Please describe any classes you are qualified to instruct
Please describe any military experience
Have you applied with Miller EMS before? If so, when?
Have you been employed with Miller EMS before? If so, when? Reason for leaving?
Do you have any friends or relatives that work for Miller EMS? If so, who?
Are you currently employed and if so where?
Are you lawfully prevented from becoming employed in this country?
Can you travel if your job requires it?
Miller EMS participates in FEMA deployments. Are you
willing to be deployed for an extended period of time out
of state?
Do you have a clean driving record? If no, please briefly explain.
Have you ever been convicted of a felony? If yes, please explain.
How did you learn about Miller EMS?
References
In the space below please list up to four references including their first and last name,
phone number, address, relation to them, and how long you have known them.
In the space below please list any additional information you feel
a need to expand on.
Initial each agreement by typing your initials beside each in the space
provided.
I certify that the answers given herein are true and complete.

I authorize investigation of all statements contained in this application
for employment.

This application shall be considered active for a period of 60 days.
Any applicant wishing to be considered for employment beyond that
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 at any time with
or without cause. This "at will" relationship may not be changed by
written document or by conduct unless such change is specifically
acknowledged in writing by the 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.
By typing your name in the box below and affixing the date you are
electronically signing this application
and attesting to the integrity of the
information provided herein.
Electronic signature                                                                     Date of application
To submit this form please click the "Submit" button in the lower left hand corner. To
reset ALL values and start over click the "Reset" button. Clicking the "Reset" button will
clear ALL fields.
If you experience technical complications with this form preventing you
from submitting your information please contact our business office
between the hours of 9am-4pm M-F.
580-395-2426
Application for employment