Application Package

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T.B. Mask Fit
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Application for employment:  Southern Paramedic Services Inc.
P.O. Box 88
Brinkley, AR 72021
Ph. 870-589-2206 Fax 870-589-2707
Please complete all necessary information. You may be asked to provide additional information on another form. This application will be kept on file for a period of 90 days. It is your responsibility to periodically check to keep it current and active. Be sure to sign and date the application.
( If you hit enter by accident just Hit the back button and your info will return.)

Name   Date of application

D.O.B.   Phone (Home) Phone (Cell)

Address

City/State/Zip

Full Time  Part Time   E.M.T. Certification #   State Position Applying For

Shirt Size E-Mail

What station would You Be Available to work at?
Brinkley      Augusta      Hazen Dispatch
Carlisle      Stuttgart      Clinton      Lonoke
Cherry Valley      Wynne

On what date would you be available for work?

Have you ever been employed here before?

Are you legally eligible for work in the U.S. Are you of legal age to work in the U.S.

                                    Name of school                                                   Did you Graduate?      Degree / Diploma / GED
Grammar School  
High School         
College                
Graduate School  
Vocational           

Membership in professional organizations ( Exclude those which may disclose you race, color, religion or national origin.)







List any additional skills or certifications which may benefit you in the performance of your job.
PALS          ACLS
BTLS          PHTLS
HAZMAT Awareness Level
CPR Health Care Provider
Any Other


Employment Experience
Use the check box by the employer (s) you do not want us to contact. List your most recent employer first.

Employer 1 Address
Phone City/State/Zip Job Title
Supervisor Work Performed
Dates Employed From To Hourly Rate (Beg.) Final
Reason For Leaving

Employer 2 Address
Phone City/State/Zip Job Title
Supervisor Work Performed
Dates Employed From To Hourly Rate (Beg.) Final
Reason For Leaving

Employer 3 Address
Phone City/State/Zip Job Title
Supervisor Work Performed
Dates Employed From To Hourly Rate (Beg.) Final
Reason For Leaving

Personal References (Other than family members or previous employers.)
1. Name Phone
2. Name Phone
3. Name Phone
4. Name Phone

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