IL APP - EMT

Personal Information

Name:

First NameLast Name

Cell Phone Number:

Area CodePhone Number

Home Phone Number:

Area CodePhone Number

E-mail Address:

Address:

Street Address

Street Address Line 2

CityState

Zip Code

General Information

Are you eligible to work in the United States?

Preferred Method of Contact:

Do you meet the 125 LBS Lift Requirement?

Desired Location for Employment:

Requested Employment Schedule:

What date are you available to start work?:

Date

EMS Credential Information

Don't have your EMT license yet? Go to EMTNOW.org!

Are you an Elite EMT Student?

Level of EMT Certification:

What EMT School did you attend?:

Not sure? Put N/A.

What EMS System are you currently in?:

Not sure? Put N/A.

Illinois Department of Public Health Certifications Number:

Expiration Date:

Date

Basic Cardiopulmonary Resuscitation Number (CPR):

Expiration Date:

Date

Advanced Cardiac Life Support (Paramedics Only):

Expiration Date:

Date

Number of Hours you would like to work per week:

Ex. 20-hours/40-hours

Employment History

Please list former/current employers with a description of your responsibilities.

Employer 1

Name:

First NameLast Name

Phone Number:

Area CodePhone Number

Years Known:

Position Title:

Brief Description of Responsibilities:

May we contact your present employer(s)?:

Employer 2

Name:

First NameLast Name

Phone Number:

Area CodePhone Number

Years Known:

Position Title:

Brief Description:

May we contact your present employer(s)?:

Have you worked for Elite before?

How did you hear about us?

Would you like a Virtual or In-person Interview?

Have you ever been the subject of a Hospital System Investigation?

Has the Illinois Department of Public Health ever suspended, revoked or refused to renew your EMT license or taken any other type of disciplinary action against you / or your EMT license including, but not limited to, letter of reprimand, letter of clinical deficiency, advisory letter?

Is there anything else you'd like us to know?

If not, please leave blank.

I represent that I have fully understood the questions above, that my answers are truthful and accurate, and that the omission of any material fact, commission of any statement, and / or any attempt to misrepresent the truth will result in immediate termination.

Please verify that you are human