online application

BronzeStar Ambulance Service does not discriminate in hiring or employment on the basis of race, color, religion, national origin, sex, ancestry, sexual orientation, age, handicap, or any other characteristic protected by Federal, State or Local law. No question on this application is intended to secure information to be used for such discrimination. It is unlawful in Texas to require or administer a lie detector test as a condition of employment or continued employment.

I recognize that any offer of employment will be conditional upon my showing documents establishing that I am authorized to be employed by BronzeStar Ambulance Service and I agree to provide such documents as required by law. This application will be given every consideration, but its receipt does not imply that the applicant will be employed.

In processing this employment application, we may request that a consumer report be prepared which may include information as to your character, general reputation, police record, CORI check, personal characteristics, and mode of living. You have the right to request that BronzeStar completely and accurately disclose to you the nature and scope of the investigation requested. Such a request must be made in writing to the Human Resources Department within a reasonable time after you complete this application.

BronzeStar Ambulance Service is authorized to obtain pertinent reference information from former employers in the processing of this application. By submitting this form, you acknowledge that you have read and understand the foregoing disclosures.

Fields with an asterisk (*) are required.

Personal Information

* Indicates required field

Name *

First

Last

Social Security Number *

Date *

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Number *

Business Number *

Can you prove your U.S. Citizenship? *

Yes No

If not a U.S. Citizen, give a Visa No. & expiration date *

Have you ever been convicted of a felony criminal offense *

Position you're applying for *

Other position (if you selected "Other...") *

Salary Requirement *

Date you can start (xx-xx-xxxx) *

How were you referred to us? *

Education Record

High School (Name, City, State) *

Business or Technical School (Name, City, State) *

Undergraduate College (Name, City, State) *

Graduate School (Name, City, State) *

Graduation Date *

Dates Attended *

Degree Earned *

Dates Attended *

Degree, Major *

Dates Attended *

Degree, Subject *

Professional Licenses or Certificates / State / License Number / Date Expires *

Work History

Company #1 (most recent)

Company *

City and state *

Dates employed (month & year) *

Describe your job duties *

Name and title of supervisor *

Street address *

Job title *

Starting and ending salary *

Reason for leaving *

Contact phone number *

Company #2

Company *

City and state *

Dates employed (month & year) *

Describe your job duties *

Name and title of supervisor *

Street address *

Job title *

Starting and ending salary *

Reason for leaving *

Contact phone number *

Company #3

Company *

City and state *

Dates employed (month & year) *

Describe your job duties *

Name and title of supervisor *

Street address *

Job title *

Starting and ending salary *

Reason for leaving *

Contact phone number *

Business References (If applying for your first job, you may use academic references)

Reference #1

Name *

City and state *

Relationship to you *

Street address *

Home phone *

Work phone *

Reference #2

Name *

City and state *

Relationship to you *

Street address *

Home phone *

Work phone *

Reference #3

Name *

City and state *

Relationship to you *

Street address *

Home phone *

Work phone *

Notification and Agreement

Please read before submitting this application.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION, OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to the employment interviewer before submitting. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

I authorize the investigation of all statements and information contained in this application. I understand that a pre-employment drug screening test will be performed. I release from all liability anyone supplying such information and I also release the employer from all liability that may result from making an investigation.

If hired, I agree to abide by all of the company rules and regulations. I understand that if employed, my employment may be terminated with or without cause and with or without notice at any time at the option of either BronzeStar Ambulance Service or me. I further understand that no representation, whether or oral or written, by any representative of agent of BronzeStar Ambulance Service, at any time, can constitute a contract of employment. I further understand that the at-will nature of my employment cannot be changed except by a formal written contract signed by an executive of BronzeStar Ambulance Service.

I understand that BronzeStar Ambulance Service and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits, or other terms or conditions of employment.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied by me on this application and in any accompanying documents. Without limiting in any way the at-will status of my employment if I am hired, I understand that if any of the statements on this application and its accompanying documents are untrue, I may be immediately discharged.

By checking below you agree to the above *

I agree

Today's date (xx-xx--xxxx) *

Submit

Employee Contact Information

* Indicates required field

Employee Name *

Emergency contact #1

Emergency contact name *

Contact number *

Relationship *

Alternate number *

Emergency contact #2

Emergency contact name *

Contact number *

Relationship *

Alternate number *

Emergency contact #3

Emergency contact name *

Contact number *

Relationship *

Alternate number *

Submit

online application

Personal Information

Education Record

Work History

Company #1 (most recent)

Company #2

Company #3

Business References (If applying for your first job, you may use academic references)

Reference #1

Reference #2

Reference #3

Notification and Agreement

Employee Contact Information

Emergency contact #1

Emergency contact #2

Emergency contact #3

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