PERSONAL INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Do you currently have a valid PA State Drivers license?

Yes No

Do you have any driving violations in the last five years?

Yes No

I would like to apply to be:

Paid Employee Volunteer

EDUCATION

Did you finish high school?

Yes No Still student

Name of High School

Year Graduated:

Did you finish college?

Yes No Still student

Name of college:

Year Graduated

Are you currently a licensed EMT?

Yes No I'm a student

License Number:

EMT Expiration date

Work Experience

Name of company:

Position:

Salary Job 1:

Start Date:

End Date:

Describe Responsibilities:

Name of company 2:

Position at job2:

Salary:

Start Date:

End Date:

Describe Responsibilities:

Notice

Pittston Township Ambulance Association takes your personal data protection seriously. We do not share your personal data with any third party without your prior consent. All information provided is confidential and securely stored using industry standard security. In the event you wish to have your information deleted please contact us by phone. In the event an offer of employment is being made, a detailed application will be required to be completed upon hire.

Is the information being submitted accurate to the best of your knowledge and do you agree to permit any research of the information contained and submitted?

Yes No

Apply For EMS Job

PERSONAL INFORMATION