Application for Employment

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We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability or any other legally protected status.

We are an Equal Opportunity Employer. * required fields HUMAN RESOURCES DEPARTMENT: Full Name (First, Middle, Last): * Street: * City: * County: State: * Zip: * Home Phone: Work Phone: Email: * Are you currently a US citizen? Are you legally authorized to work for SVEMS in the United States? (Proof of citizenship or immigration status will be required upon employment.) Yes No EMPLOYMENT DESIRED: Position for which you are applying: Check the items you will consider: Part-time Full-time Evenings Days Nights Weekends Date you can start: Have you ever worked for SVEMS? Yes *   No * If yes, when?: Apart from absence for religious observance, are you available for full-time work? Yes   No * * If not, what hours can you work?: LICENSURE: If you are licensed or certified to perform the duties for which you are appliying, complete the following: Licensed or certified by: License, certification, or registration number Exp. Date EMPLOYMENT HISTORY: Please List your last 3 employers, starting with the most recent: Most Recent Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No Previous Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No Previous Employer Name of Employer: Address: Dates of Employment: From to Salary/Wage: Position: Reason for Leaving: Duties Performed: Supervisor's Name and Phone Number: May We Contact? Yes   No If your name has been changed since you previously worked here or at the companies above, please type your previous name here: REFERENCES: Please give the names of three individuals whom you have known for at least one (1) year. NO relatives please. Name Address Telephone EDUCATION: Elementary: Name of School Location of School # of Years Attended Did you Graduate Yes   No Subjects Studied/Degrees Received High School: Name of School Location of School # of Years Attended Did you Graduate Yes   No Subjects Studied/Degrees Received Trade, Business, Technical School Name of School Location of School # of Years Attended Did you Graduate Yes   No Subjects Studied/Degrees Received College Name of School Location of School # of Years Attended Did you Graduate Yes   No Subjects Studied/Degrees Received Graduate Name of School Location of School # of Years Attended Did you Graduate Yes   No Subjects Studied/Degrees Received OTHER INFORMATION: Have you ever been disciplined or discharged due to an act of violence in the workplace? Yes   No Have you ever pleaded guilty to or been convicted of any crime other than a minor traffic offense? Yes   No * If yes, please explain... (Conviction will not necessarily disqualify applicant from employment.) Are you capable of performing in a reasonable manner the esential fuctions and activites involved in the job for which you have applied with or without reasonable accommodation? Yes   No Do you have any relatives working here? Yes   No * If yes, Name/Dept. (Entity) I understand that due to the nature of the job, I may be required to work overtime. CONSENT TO PERFORM I am an applicant for employment at Susquehanna Valley Emergency Medical Services, Inc. I understand that my physical condition may affect my work performance and my ability to carry out my job duties, and may endanger the safety and welfare of patients and employees at Susquehanna Valley Emergency Medical Services, Inc. In order to enable Susquehanna Valley Emergency Medical Services, Inc. to fulfill its obligation to provide a safe environment for patients and employees, I CONSENT TO THE PERFORMANCE OF A POST OFFER MEDICAL EXAMINATION AND DIAGNOSTIC PROCEDURES, including but not limited to the collection of blood and/or urine samples to test the presence of alcohol and/or drugs and/or chest x-ray. I furthermore AUTHORIZE THE RELEASE of any and all medical information obtained during the examination and testing procedures to the Susquehanna Valley Emergency Medical Services, Inc. I understand that at ANY TIME during my employment I may be tested for drugs and/or alcohol. If the results of such testing are CONFIRMED POSITIVE or I refuse to cooperate fully with a medical examination or testing procedures I may be subject to discipline, including termination. I release Susquehanna Valley Emergency Medical Services, Inc. and its employees, agents and physicians from any claims, liability or damages arising out of its performance of a medical and/or diagnostic procedure. Name/Signature:*     Date:   9/8/2010 I hereby authorize Susquehanna Valley Emergency Medical Services, Inc. and their representatives to consult with administrators/ supervisors and academic institutions with which I have been associated and with others who may have information bearing on my professional competence. I hereby release from any liability any and all individuals and organizations listed above who provide information to the Susquehanna Valley Emergency Medical Services, Inc. in good faith concerning my professional competence, educational credentials, ethics, character and other qualifications and I hereby consent to the release of such information. Name/Signature:*     Date:   9/8/2010 With the submission of this application I certify that all statements are true and correct to the best of my knowledge and belief. Any misrepresentation or omissions on this application may be sufficient cause for rejection of the application or dismissal after employment. The offer of employment is conditional pending final approval of the employment physical examination which includes a substance and alcohol screen, and successful completion of the orientation period. It is understood that my employment with the Susquehanna Valley Emergency Medical Services, Inc. is AT WILL and may be discontinued at any time by either the Susquehanna Valley Emergency Medical Services, Inc. or myself. If accepted for employment I hereby agree to abide by the rules and policies of my employer. Name/Signature:*     Date:   9/8/2010 Completion of the following data is voluntary and will not affect your opportunity for employment or terms or conditions of employment, if hired. Identification can be declared at any time prior to or, if applicable, after hire. Please print, fill out, and return the following PDF with your application to: SVEMS, P.O. Box 1, Landisville, PA 17538. Thank You. Download Voluntary Self-Identification Form (.PDF)