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?*

YesNo

Preferred Method of Contact:*

Cell PhoneHome PhoneEmail

Do you meet the 125 LBS Lift Requirement?*

YesNo

Desired Location for Employment:*

Requested Employment Schedule:*

Full TimePart Time

What date are you available to start work?:*

Date

EMS Credential Information

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

Level of EMT Certification:*

EMR - Emergency Medical ResponderEMT-B - Emergency Medical TechnicianEMT-P - ParamedicCCEMT-P - Critical Care Paramedic

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)?:*

YesNo

Employer 2

Name:

First NameLast Name

Phone Number:

Area CodePhone Number

Years Known:

Position Title:

Brief Description:

May we contact your present employer(s)?:

YesNo

Have you worked for Elite before?*

YesNo

How did you hear about us?*

Would you like a Virtual or In-person Interview?*

VirtualIn-Person

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

YesNo

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?*

YesNo

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*