Bartlesville Ambulance Employment Application

Applicant Information

                        Note: Must Obtain State License

                            Education Information
                            High School Education
                                      College Education
                                                Trade, Business, or Correspondence School
                                                          Past Employment Information
                                                          Employer 1

                                                                                Employer 2

                                                                                                      Employer 3

                                                                                                                            Employer 4
                                                                                                                                                  Professional References
                                                                                                                                                  Reference 1

                                                                                                                                                                      Reference 2

                                                                                                                                                                                          Reference 3

                                                                                                                                                                                                              Reference 4

                                                                                                                                                                                                                                  By submitting this form, I authorize investigation of all statements contained herein and the references and employment listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

                                                                                                                                                                                                                                  I also understand and agree that no repesentative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it si in the writing and signed by an authorized company representative.

                                                                                                                                                                                                                                  I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

                                                                                                                                                                                                                                  This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.


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