OCA Employment Application Thank you for your interest in a position at Orange Cross Ambulance. Orange Cross Ambulance is committed to providing equal employment opportunity to all applicants and employees regardless of their race, color, religion, age, sex, national origin, disability, military service, protected veteran status, genetic information, sexual orientation, gender identity, or any other characteristic protected by federal, state or local law. We are strongly committed to this policy and believe in the concept and spirit of the law. Demographics Question Title * 1. Please provide your contact information. Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Are you authorized to work lawfully in the United States for Orange Cross Ambulance, Inc. Yes No Question Title * 3. Are you under the age of 18? Yes No If yes, please state age. Question Title * 4. Do you hold a valid State of Wisconsin EMS Provider license? Yes No Question Title * 5. What is your current level of Wisconsin EMS Licensure? EMR (Emergency Medical Responder) EMT (Emergency Medical Technician) AEMT (Advanced Emergency Medical Technician) Paramedic Paramedic with Critical Care Endorsement Applying for Operations, Admin, Billing, or Support role Question Title * 6. State of Wisconsin License # (enter 0000 if you are not a licensed EMS provider) Question Title * 7. What type of position are you applying for? Licensed Full-Time EMT, AEMT, Paramedic, Critical Care Paramedic Licensed Part-Time EMT, AEMT, Paramedic, Critical Care Paramedic Communications Specialist Admin, Operations, Billing, Support Education Question Title * 8. Schools Attended High School Name, City, State, Graduation Year College or University Name, City, State, Graduation Year Technical School Name, City, State, Graduation Year Other Education, Special Training, or Courses Completed, Graduation Year EMPLOYMENT HISTORY Question Title * 9. Present Employer: Supervisor Name Company Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 10. Present or Last Employer #2 Supervisor Name Company Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number CRIMINAL HISTORY(A conviction or arrest record does not automatically disqualify you from employment) Question Title * 11. Have you ever been convicted of or pled "No Contest" to a crime (other than a minor traffic violation)? Yes No If yes, please provide: (1) A description of the nature of the conviction(s); (2) The location(s); and (3) The date(s) of conviction: Question Title * 12. Are there any pending criminal charges against you? Yes No If yes, please provide: (1) A description of the nature of the crime(s); (2) The state in which such charge(s)is (are) pending; and (3) The date(s) on which such charge(s) was (were) issued: I understand that my admission to an arrest or conviction does not automatically disqualify me from employment or volunteering. I further understand that failure to disclose any such information will be sufficient cause for cancellation of further consideration as an employee or volunteer or my discharge at any time. Question Title * 13. If you were referred to Orange Cross Ambulance by a current Orange Cross Employee, please enter the referring employee's name here. PLEASE READ BEFORE AUTHORIZING:I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS CORRECT AND MAY BE INVESTIGATED. I understand that if, in the judgment of Orange Cross Ambulance, any information has been misrepresented, falsified or omitted, any offer of employment may be withdrawn or any employment terminated without obligation or liability on the part of Orange Cross Ambulance. I authorize Orange Cross Ambulance to act as my AGENT in obtaining information from any person or company concerning myself, without liability to such person or company, or to Orange Cross Ambulance. I understand that Orange Cross Ambulance operates 24 hours per day, 7 days a week, and that weekend work or changes may be required during my employment. I understand also that my employment at Orange Cross Ambulance is conditional upon completion of the pre-employment drug test, criminal background check, physical examination, and test to be performed by a designate of Orange Cross Ambulance and certification by Aurora Occupational Health that I am able to undertake the job duties of the position to be filled. I understand that if I am employed by Orange Cross Ambulance, any such employment is not binding on either party for any specific period of time. I understand that if employed I will be an employee-at-will and that either Orange Cross Ambulance or I may terminate that employment relationship at any time, for any reason, with or without notice. Question Title * 14. Please check yes if you have read the certification statement, understand that incomplete applications will not be considered, and authorize the submission of this application in agreement with the statement above. Yes No 100% of survey complete. Submit
