Apply — Millstadt Ambulance Service | Millstadt Ambulance Service

1

Position Applied For

Select the role you are applying for and your availability.

Employment Type — Select all that apply *

Full-TimePart-TimePRNVolunteer

Preferred Shift / Notes

2

Personal Information

All fields are required unless noted.

First Name *

Last Name *

Middle Name

Date of Birth *

Social Security Number *

Phone Number *

Email Address *

Street Address

City, State, ZIP

Driver's License State

Driver's License Number

Driver's License Expiration

3

Eligibility & Background

If yes to any above, please explain

I consent to the following checks

Background CheckDrug ScreeningDriving Record Check

4

Education

High School

College / University

Institution Name

Degree

Graduation Year

Cumulative GPA

University Honors

5

Licensure

Provide details on your professional EMS / medical licenses.

Primary License

Additional License (optional)

NREMT

DEA Registration (if applicable)

6

Certifications

Enter card numbers and expiration dates. NIMS and HazMat just need a Completed checkbox.

Certification

BLS

Card #

Expires

Certification

ACLS

Card #

Expires

Certification

PALS

Card #

Expires

Certification

ITLS / PHTLS

Card #

Expires

Certification

NRP

Card #

Expires

Certification

FP-C / CCP-C

Card #

Expires

Certification

CPI / De-escalation

Card #

Expires

Certification

HazMat Awareness/Ops

Status Completedno expiration

Certification

FEMA NIMS IS-100

Status Completedno expiration

Certification

FEMA NIMS IS-200

Status Completedno expiration

Certification

FEMA NIMS IS-700

Status Completedno expiration

Certification

FEMA NIMS IS-800

Status Completedno expiration

7

Work History

List relevant EMS/medical employment — most recent first.

Employer #1

Agency Name

Position Title

From

To

Full / Part / PRN

Supervisor & Contact

Reason for Leaving

Job Duties

Employer #2

Agency Name

Position Title

From

To

Full / Part / PRN

Supervisor & Contact

Reason for Leaving

Job Duties

Employer #3

Agency Name

Position Title

From

To

Full / Part / PRN

Supervisor & Contact

Reason for Leaving

Job Duties

8

EMS Experience

Years of EMS Experience

Years of ALS Experience

Years of Critical Care

9

Driving History

If yes to any above, please explain

10

Professional References

Minimum of 3 references required.

Reference #1

Name

Title

Relationship

Phone / Email

Reference #2

Name

Title

Relationship

Phone / Email

Reference #3

Name

Title

Relationship

Phone / Email

11

Additional Information

Why do you want to work for Millstadt Ambulance Service?

What are 5 goals you have for the next 5 years?

Personal, professional, educational, financial — anything. List five things you're working toward.

12

Attachments

Upload your resume, license copies, and certifications. 4MB total maximum.

Resume / CV

Cover Letter

Driver's License Copy

Professional Licenses

Certification Cards

Immunization Records

Additional Documents

13

Applicant Certification

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that falsification or omission of information may result in disqualification from consideration or termination of employment. I authorize Millstadt Ambulance Service to verify any of the information provided and to contact references and former employers.

I certify the above and agree that all information is true and complete. I consent to the background, drug, and driving record checks I selected above.

Applicant signature

Sign below to certify everything above. Your signature is recorded on the application PDF that is sent to Millstadt EMS along with the date and time of signing.

Sign here

A signature is required to submit.

Apply to Millstadt EMS

Position Applied For

Personal Information

Eligibility & Background

Education

Licensure

Certifications

Work History

EMS Experience

Driving History

Professional References

Additional Information

Attachments

Applicant Certification