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.

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