Employment Application Thank You! for your interest in joining the Explorer – 1 Team Step 1 of 7 14% Your InformationPlease provide complete information for all form fields.Your Legal Name*Please Provide Your Full Legal Name First Middle Last Address*Please provide your current address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email Address* Enter Email Confirm Email Your Primary Phone*Telephone Type* Home Cell Other Do You Have a Secondary Phone No.? Yes No What is The Best Time To Call You?Best Time To Call YouMorningsEarly AfternoonLate AfternoonEarly EveningWhen is the best time for us to reach you?Secondary Phone No.*Telephone Type* Home Cell Other Are You 18 Years of Age?YesNo(The Law Prohibits Discrimination Against Anyone at Least 40 Years or Older) Social Security Number Please provide the last 4 digits of your Social Security Number. The full Social Security Number can be supplied in person.Do You posses a Driver's License and/or Identification Card? CA Driver's License I Posses Both Identification I do not posses either Driver’s License Number* Issuing State*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDriver's License Class*CLASS - CCLASS - BCLASS - AOtherID InformationIf your Identification number is different than your Driver's license number, please provide the information My Identification Number is Identification My Driver's License Identification Number Issuing StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYHave You Ever Applied or Were Employed by Explorer - 1?NoYesIf Yes, When? MM slash DD slash YYYY What Position?EMTEMT-PECTEMDRNMDOtherDo You Have Any Relatives Working for Explorer - 1?NoYesIf Yes, what is the relationship? What is the relative name? IntroductionTell Us About YourselfPlease provide a brief and relevant summary about yourself. Education and TrainingPlease Provide Educational Achievements such as: High School, GED, College, Specialized Training, Trade School, etc...What Are Your Educational Achievements? High School College Vocational/Technical School Other Select AllPlease select one or multiple options, and use the "Select All" button when all options apply to you. The "High School" or "Other" option must be selected as one of your minimal "Educational Achievements."High School Please Provide City and State City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Academic AchievementHigh School DeplomaGEDOtherSubjects/Classes/Course Please list your classes or course of study.Formal, Informal and Other Type of Education:* Adult School Home School Boarding School Non Formal Education Alternative Education Apprenticeship Other Your answers will not disqualify you from the possibility of employment.What is the highest level of education and or experience in Lieu of education you’ve achieved?* Did You Receive:* GED HiSET TASC Other College, University, InstituteCollege* Please Provide City and State* City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State How long did you attend college?* Semester Multiple Semesters, But less Than 1-Year Greater Than 1-Year Years Completed*Please enter a number from 0 to 12.Area of Study:* Degree Level or Certification Received*Semester Course CompletionProfessional CertificatesUndergraduate DegreesTransfer DegreesAssociate DegreesBachelor’s degreesGraduate DegreesMaster’s degreesDoctoral DegreesProfessional DegreesSpecialist DegreeCourse Completion, Certification or Achievement:*Semester Course CompletionProfessional CertificatesTransfer CreditsVocational/Technical School TrainingVocational/Technical School* City and State* City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State How long did you attend Vocational/Technical School?* Semester Multiple Semesters, But less Than 1-Year Greater Than 1-Year Apprenticeship Years Completed*Please enter a number from 0 to 12.Course/Apprenticeship/Major* Certification, Licensure, Degree Received:* What Position Are You Applying For?Please select the position title you are applying for and complete all form fields.Position Title:*EMTEMT-PECTEMDRNMDVehicle Maintenance Tech.Community Task Force (Volunteer Cadet)Location*ComptonEmployment Desired?*Full-TimePart-TimePer DiemEmployeeTemporaryContractInternVolunteerWhen Can You Start?* What Hours Are You Available for Work?Please list your hour of availability for each day of the week or list total hours you would like to work for each day.SundayMondayTuesdayWednesdayThursdayFridaySaturdayHow Did You Learn of This Position?*Recruitment FlyerRecruitment EventSocial MediaInternetRadioFriendOther Employment and/or Volunteer ExperienceExplorer - 1 is an equal opportunity employer and selects the best individuals for the job based upon job-related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, age, veteran status, ancestry, marital status, or disability. Explorer - 1 will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation imposes an undue hardship on the operation of our business.Have You Ever Been Employed or Performed Volunteer Work?* Yes, I have been employed Yes, I have both been employed and performed volunteer work Yes, I have performed volunteer work No, I have not held employment Please provide a brief description of the volunteer work you have performed and the organization you have volunteered for.*Your answer does not disqualify you for potential employment. Please provide a brief description or reason as to why you have not held employment*Your answer does not disqualify you for potential employment. Most Recent Employer InformationPlease provide complete information in the form fields on your most recent employer.Name of Employer* Employer Phone No.*Position* List Base Salary*Recent Employer Address* City* State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Name of Supervisor Start Date* Are you currently still employed?* Yes No End Date* Responsibilities*Please provide a brief description of your duties and responsibilities. Reason For Leaving*Please provide a reason for leaving the employer Former Employment HistoryPlease provide complete information on your former employer.1. Name of Former Employer 1. Employer Phone No.*1. Position* 1. List Base Salary*1. Former Employer Street Address* 1. City* 1. State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific1. Zip Code* 1. Name of Supervisor 1. Start Date* End Date* 1. ResponsibilitiesPlease provide a description of your duties and responsibilities. 1. Reason For LeavingPlease provide a reason for leaving the employer. 2. Name of Former Employer 2. Employer Phone No.2. Position* 2. List Base Salary2. Former Employer Street Address* 2. City* 2. State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific2. Zip Code* 2. Name of Supervisor 2. Start Date* 2. End Date* 2. ResponsibilitiesPlease provide a description of your duties and responsibilities. 2. Reason For LeavingPlease provide a reason for leaving the employer. Upload Your ResumeUpload your resume in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 100 MB.ReferencesPlease list your professional and work-related references. Press the plus button to add additional references.NameRelationshipDaytime PhoneEvening Phone Add Remove Professional Licensure, Certification, AccreditationPlease provide licensure, certification, or accreditation information if you apply for the EMT, EMT-P, ECT, EMD, RN, or MD position.Professional Licensure*EMTEMT-PECTEMDRNMDOtherNot ApplicablePlease select the licensure you possess.Licensure/Certification Number* Issue Date* Expiration Date* County of Accreditation*Los Angeles CountyKern CountyOrange CountyRiverside CountySan Diego CountySanta Barba CountyVentura CountyOtherPlease provide the county of accreditation.State of Issue*CaliforniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDo you possess National Registry Certification* Yes No Other Type of Licensure:*Please provide the licensure you possess. Other Licensure/Cert. Number*If your other licensure have a certification number, please provide the information. Issue Date* Expiration Date* Certification Information.Please provide certification information if you possess a CPR, ACLS, or PALS certification.What Certification do you posses?Please select all certifications that you posses. CPR Certification ACLS Certification PALS Certification NPR Certification Other None CPR CertificationPlease provide the level of CPR training that you have received.1. CPR Certification*CPR - BLS/HCPCPR - AEDCPR - First AIDCPR - Hands Only/Friends & FamilyCPR - Adult OnlyCPR - Child & InfantCPR - Adult, Child & InfantIssuing Organizations*AHARed CrossAHSIPlease be advised AHA and Red Cross are the preferred organizations for Los Angeles County EMS. Issue Date* Expiration Date* Please upload a copy of the front and back (if applicable) of your professional CPR certifications. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB, Max. files: 2. ACLS | Advanced Cardiovascular Life Support CertificationPlease provide Advanced Cardiovascular Life Support (ACLS) certification information you have received.ACLS Issuing Organization*AHARed CrossAHSIIssue Date* Expiration Date* Please upload a copy of the front and back (if applicable) of your professional ACLS certifications. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB, Max. files: 2. PALS | Pediatric Advanced Life Support CertificationPlease provide Pediatric Advanced Life Support (PALS) certification information you have received. A copy of the certification must be uploaded.PALS Issuing Organization*AHARed CrossAHSIIssue Date* Expiration Date* Please upload a copy of the front and back (if applicable) of your professional PALS certifications. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB, Max. files: 2. NPR | Neonatal Resuscitation Program CertificationPlease provide Neonatal Resuscitation Program (NPR) certification information you have received.|NPR Issuing Organization*AHARed CrossAHSIIssue Date* Expiration Date* Please upload a copy of the front and back (if applicable) of your professional PALS certifications. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB, Max. files: 2. Other Type of Certifications:Please list all other professional certifications related to the position you are applying for.Other Professional CertificationsPlease list all "Other" certifications.CertificationIssuing AgencyIssue Date: mm/dd/yyyyExpiration Date: mm/dd/yyyy Add RemovePlease upload a copy of the front and back (if applicable) of your profession certifications listed above.. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB, Max. files: 8. Please Read and Carefully Complete All QuestionsIf you answered yes to any question, with the exception of questions 1 and 9, please briefly explain.1. Are You Legally Eligible for Employment In The U.S.?* Yes No 2. Have You Ever Been Fired or Asked To Resign From Any Job?* Yes No If Yes, Please List The Employer, Date, and Reason:*Your answer does not disqualify you from potential employment. 3. Have You Ever Been Refused Bond/Insurance From Any Bond/Insurance Company?* Yes No If Yes, Please List The Employer, Date, and Reason:*Your answer does not disqualify you from potential employment. 4. Is There Any Reason You Could Not Adequately Perform The Essential Duties of The Job For Which You Have Applied?* Yes No Your answer does not disqualify you from potential employment.If Yes, Please Explain The Reason You Could Not Adequately Perform The Essential Duties:*Your answer does not disqualify you from potential employment. 5. Have You Ever Had Your Emergency Medical Technician, Paramedic, Registered Nurse, Medical License or Vocational License Suspended or Revoked?* Yes No If Yes, Please Explain The Reason:Your answer does not disqualify you from potential employment. 6. Have You Been Cited For Any Moving Violation In The Last Three Months?* Yes No If Yes, Please Explain The Reason:Your answer does not disqualify you from potential employment. 7. Have You Had Any Accidents In The Last Three Years?* Yes No If Yes, Please Explain The Reason:*Your answer does not disqualify you from potential employment. 8. Has Your Driver's License Ever Been Suspended, Revoked, Denied or Canceled?* Yes No If Yes, Please Explain The Reason:*Your answer does not disqualify you from potential employment. 9. Do You Posses A California Ambulance Driver's License?* Yes No Explorer - 1 Is an Equal Opportunity EmployerExplorer - 1 is an equal opportunity employer and selects the best individuals for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, age, veteran status, ancestry, marital stat us, or disability. Explorer - 1 will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability, unless the accommodation will impose an undue hardship on the operation of our business.Please Read Each Statement Carefully Before Signing*I certify, understand, and agree that all information provided in this employment application and submitted by myself is true and correct. I understand that any false information or omission within this application or interview may disqualify me from further consideration for employment and may result in my immediate dismissal and/or discharge if discovered at a later date. I understand that if I am offered employment, I am required to abide by all rules and regulations of Explorer – 1. I Understand that if I am offered employment, my employment will be contingent upon my successful completion of a probationary period. I understand that I will be required to possess a current valid California driver's license if my job requires me to drive in the course of my work. I understand that the information I supplied regarding my employment history, education (including authorization to release transcripts), credit history, criminal history, medical and professional licensing, motor vehicle record/s, residence history, and references will be utilized as the processing procedure. Upon acceptance of a formal employment offer, A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information about my character, general reputation, personal characteristics, and mode of living. I Authorize the thorough and complete investigation of my work, personal history, credit, activities, and any or all statements contained in this application; I also authorize any person, school, current employer (except as previously noted), past employers, companies, corporations, and organizations to release the information (including paper, oral, and electronic interchange); I will hold no persons liable for giving or receiving information in this investigation, and I release all from any legal liability in making such statements. I hereby fully waive any rights or claims I have or may have against all current and/or former employers and their agents, employees, and representatives and damages that may directly or indirectly result from the use, disclosure, or release of any information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claims against Explorer - 1 Ambulance & Medical Services, LLC, and any outside agency utilized by Explorer - 1 as a result of any information that is obtained in this investigation. This application is submitted with the understanding that upon acceptance of a formal employment offer, the employer may request an investigative consumer report agency, as well as a check of my criminal record. I understand that should this application or a criminal record check reveal a conviction of a crime, further processing of this application or my employment, if hired, may be terminated; I also understand I will be required to pass successfully: Explorer -1 Pre-Placement Testing, Assessment Field Ride-Along, and a Drug and Alcohol Screen. I also consent to the release of any and all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I also certify that I have no medical disabilities that will prevent me from performing the job duties that I am applying for. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER, AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE, AT THE OPTION OF THE COMPANY OR MYSELF. I Certify I Have Fully Read and Understand All Sections of This Application and The Questions I am required To Answer; I Also Certify That all information provided in this employment application is true and correct. I understand that any false statement or omission may disqualify me from further consideration for employment and may result in my immediate dismissal if discovered at a later date.Signature*Please Sign to Complete ApplicationDate* MM slash DD slash YYYY Untitled First Choice Second Choice Third Choice NameThis field is for validation purposes and should be left unchanged.
