First Name
Last Name
Street Address
Address (cont'd)
City
State
Zip Code
Phone #1
Phone #2
E-mail
Area of Interest:	Northeast Ohio  Central Ohio  Southwest Ohio
Requested Status	Full-Time  Part-Time
Ohio EMS Certification Level	EMT-B   EMT-I   EMT-P
Ohio EMS Certification #
Last 4 digits of your Social Security Number
Date of Birth (month/day/year)
State In Which Drivers License Is Issued
Drivers License #
What is the best time to contact you?	Morning  Afternoon  Evening
Additional Information or paste resume' here

BY SUBMITTING THIS APPLICATION, I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT ANY FALSIFICATION, MISREPRESENTATION OR OMISSION 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.

I AUTHORIZE LIFECARE MEDICAL SERVICES TO CONTACT PAST EMPLOYERS FOR EMPLOYMENT VERIFICATION AND REFERENCES.

THIS APPLICATION WILL BE GIVEN EVERY CONSIDERATION, BUT ITS RECEIPT DOES NOT IMPLY THAT THE APPLICANT WILL BE EMPLOYED.

IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES AND APPLICANTS FOR EMPLOYMENT BE GIVEN EQUAL OPPORTUNITY WITHOUT REGARD TO AGE, RACE, RELIGION, COLOR, SEX, NATIONAL ORIGIN, MARITAL STATUS, EXPUNGED JUVENILE RECORDS, OR PREGNANCY. IN ADDITION, OUR COMPANY GRANTS EQUAL OPPORTUNITIES TO ALL DISABLED VETERANS, VETERANS OF THE VIETNAM ERA, INDIVIDUALS WITH A DISABILITY AND/OR ANY OTHER PROTECTED CHARACTERISTICS AS IDENTIFIED BY FEDERAL, STATE, AND LOCAL LAWS.

I FURTHER UNDERSTAND THAT ANY OFFER OF EMPLOYMENT IS CONDITIONED ON THE COMPLETION OF PRE-EMPLOYMENT TESTING AND DOCUMENTATION. ALL INFORMATION IN THIS APPLICATION WILL BE INVESTIGATED. MY SUBMISSION OF THIS APPLICATION INDICATES MY AGREEMENT TO, UPON REQUEST, SIGN ALL NECESSARY CONSENT FORMS AUTHORIZING SUCH TESTS AND INVESTIGATIONS. I RELEASE FROM ALL LIABILITY ANYONE SUPPLYING SUCH INFORMATION, AND I ALSO RELEASE THE EMPLOYER FROM ALL LIABILITY THAT MIGHT RESULT FROM MAKING AN INVESTIGATION.  BY SUBMITTING THIS APPLICATION I AUTHORIZE LIFECARE MEDICAL SERVICES, INC, AND OR IT'S AUTHORIZED AGENTS, TO USE INFORMATION CONTAINED IN THIS APPLICATION FOR EMPLOYMENT PURPOSES ONLY INCLUDING MOTOR VEHICLE RECORD CHECKS, DRUG/ALCOHOL TESTS, AND CRIMINAL BACKGROUND INVESTIGATIONS.

BY SUBMITTING THIS APPLICATION I AGREE TO SUBMIT TO A MOTOR VEHICLE RECORD CHECK, PRE-EMPLOYMENT DRUG/ ALCOHOL SCREEN, AND CRIMINAL RECORD CHECK THROUGH OHIO BCI&I AND OR FBI.

IF HIRED, I AGREE TO ABIDE BY ALL THE COMPANY RULES AND REGULATIONS, AND UNDERSTAND THAT, IF EMPLOYED, I AM EMPLOYED AT WILL AND THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF THE COMPANY OR ME. I FURTHER UNDERSTAND THAT NO REPRESENTATION, WHETHER ORAL OR WRITTEN BY ANY AGENT OF THE COMPANY, AT ANY TIME, CAN CONSTITUTE A CONTRACT OF EMPLOYMENT. I UNDERSTAND THAT THE COMPANY 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.

BY INSERTING YOUR INITIALS AS AN ELECTRONIC SIGNATURE, AND USING THE “SUBMIT” BUTTON BELOW, I AM SUBMITTING MY APPLICATION FOR EMPLOYMENT TO LIFECARE MEDICAL SERVICES; AND I AM ACKNOWLEDGING THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS, AND AGREE TO ALL ITEMS OUTLINED ABOVE.

  APPLICANT'S INITIALS (AS ELECTRONIC SIGNATURE)

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