EMT
WI - Reedsburg
Part-Time
City of Reedsburg Ambulance, WI
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Part-Time
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Application Specific Questions
Drivers License Number
Drivers License State
Are you over 18 years old
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Are you a United States citizen?
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Have you ever been convicted of a felony?
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If yes, please list any felonies here or put NA
List all moving violations or convictions and accidents and any suspensions or revocations of your license in the last five years
Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a DUI DWI?
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If yes, please list any felonies here or put NA
Has your drivers license ever been suspended or revoked?
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If yes, please list any felonies here or put NA
Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid?
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If yes, please list any felonies here or put NA
High School Attended
Colleges Attended
College Degrees
EMS License Level
EMS License Number
Please list all previous employment on your Resume.
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I have done this
Have you ever had any of the following, if you answer yes, please explain here or put NA
Disciplined or terminated for reckless driving?
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Placed on probation or terminated for excessive absenteeism?
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Disciplined or fired for insubordination?
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Disciplined or fired for violation of safety rules?
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Disciplined or fired for assault or fighting?
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Disciplined or fired for harassment?
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Disciplined or fired for patient abuse?
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Disciplined or fired for alcohol or drug related activity at work?
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Disciplined by a previous Medical Director?
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Disciplined by a State EMS Office
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Professional Reference 1, please list name, phone, and email.
Professional Reference 2, please list name, phone, and email.
Professional Reference 3, please list name, phone, and email.
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