PERS ONA L INFORMATION - Priority Ambulance

1 APPLICATION FOR EMPLOYMENTPLEASE READ CAREFULLYPER SONAL I NFORMAT I O PRINT IN BLACK INK OR TYPE IN APPLICABLE SPACES. ANY OMISSION OF INFORMATION (EXCEPT AS NOTED BELOW) WILL INVALIDATE YOUR APPLICATION FROM NAMEFIRST NAMEADDRESSAPT. YOU UNDER 21 YRS. OF AGE?NO IF YES, STATE AGE:HAVE YOU APPLIED WITH Priority Ambulance , INC. BEFORE?NO IF YES, WHEN:POSITION APPLYING FOR:SALARY/HOURLY WAGEDESIRED:DATE AVAILABLE:INDICATE SHIFT NEED/PREFERENCE: 9-HR M-F 12-HR DAY / NIGHT 24 HR: ABC 11-HRAVAILABILITY:FULL TIIME P/T- PRNDID YOU LEARN OF THE POSITION FROM AN EXISTING OR FORMER Priority Ambulance , INC. EMPLOYEE? YES NOIF YES, EMPLOYEE-NAME:_____ARE YOU RELATED IN ANY WAY TO THIS EMPLOYEE?: YES NOUSA CITIZENSHIP STATUS:UNITED STATES CITIZENNON-CITIZEN: Permanent Resident Ali en Registration No.

2 :NON-CITIZEN: Visa Number and Expiration Date:CAN YOU PROVIDE LEGAL PROOF OF ELIGIBILITY TO WORK IN THE US? YES NOE D U C A T I O NS C H O O L N A M E, ADDRESS & T E LEPH O N EFROMTOGRADUATED DIPLOMADEGREE-TypeCOURSESM ajorGRADE gh School or Highest Grade CompletedYesYesCityStZipPhoneNoNoCollege or UniversityYesYesCityStZipPhoneNoNoProfes sional or Technical SchoolYesYesCityStZipPhoneNoNoL I C E N S E S / C E RTIF I C A T I O N S Su b mi t co p ies of all ca rd LICENSE OR CERTIFICATIONCERTIFICATION NUMBERISSUANCE DATEEXPIRATION DATEINSTRUCTOR?YES / NOYES / NOYES / NOYES / NOYES / NOHS DiplomaGEDEMT-PEMT-IEMTP aramedicE M P L O Y M ENT H ISTOR YEMPLOYERTELEPHONEDATE EMPLOYEDFROM: TO:ADDRESS:JOB TITLE:STARTING HOURLY RATE/SALARY: $ FINAL HOURLY RATE/SALARY: $ SUMMARIZE THE NATURE OF THE WORK PERFORMED AND JOB RESPONSIBILITIES:IMMEDIATE SUPERVISOR & TITLE:TELEPHONE NO.

3 :MAY WE CONTACT THIS EMPLOYER:YES / NOREASON FOR LEAVING:EMPLOYERTELEPHONEDATE EMPLOYEDFROM: TO:ADDRESS:JOB TITLE:STARTING HOURLY RATE/SALARY: $ FINAL HOURLY RATE/SALARY: $ SUMMARIZE THE NATURE OF THE WORK PERFORMED AND JOB RESPONSIBILITIES:IMMEDIATE SUPERVISOR & TITLE:TELEPHONENO.:MAY WE CONTACT THIS EMPLOYER:YES / NOREASON FOR LEAVING:EMPLOYERTELEPHONEDATE EMPLOYEDFROM: TO:ADDRESS:JOB TITLE:STARTING HOURLY RATE/SALARY: $ FINAL HOURLY RATE/SALARY: $ SUMMARIZE THE NATURE OF THE WORK PERFORMED ANDJOB RESPONSIBILITIES:IMMEDIATE SUPERVISOR & TITLE:TELEPHONE NO.:MAY WE CONTACT THIS EMPLOYER:YES / NOREASON FOR LEAVING:REFERENCES PROFESSIONALList at least 2 professional REFERENCE 1 NAMETELEPHONEPROFESSIONAL REFERENCE 2 NAMETELEPHONEPROFESSIONAL REFERENCE 3 NAMETELEPHONEREFERENCES PERSONALList at least 3 personal references not related to REFERENCE 1 NAMETELEPHONEHOW DO YOU KNOW THIS PERSON?

4 PERSONAL REFERENCE 2 NAMETELEPHONEHOW DO YOU KNOW THIS PERSON?PERSONAL REFERENCE 3 NAMETELEPHONEHOW DO YOU KNOW THIS PERSON?CRI M I N AL C ONV I C T IONSHave you, within the last seven years, been convicted of or pleaded guilty or nolo contendere (no contest) to a felony crime? (Convictions that have been expunged, sealed or legally eradicated need not be listed.) Check One YES NOIf YES, state the nature of the crime(s), when and where convicted and the disposition of the case. A conviction will not necessarily disqualify you from employment. The nature of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may be you perform the essential functions of this job, with or without reasonable accommodation? Check YES NOCan you meet the attendance requirements of this job? Check YES NOIf hired, I will provide proof of my legal authorization to work in the United M I N AL I N V ESTI G A T ION CONSEN TI, _____, hereby authorize Priority Ambulance , Inc.

5 To receive and share any criminal history record INFORMATION , with perspective employers pertaining to me which may be in the files of any state or local criminal justice agency in :SignatureI hereby state that the INFORMATION given by me in my employment application is true and complete in all respects. I understand that in consideration of my application, an investigation may be conducted of my past employment and activities. I authorize past employers, personal references and any other persons with whom I am acquainted to answer all questions asked concerning my previous employment record, ability, military service, educational background, medical history, criminal record history, credit history, driving record, workers compensation claims, character and reputation. I release all persons, including past employers, credit bureaus and government agencies, from any liabilities or damages on account of having furnished such INFORMATION in good consideration of my application, I authorize Priority Ambulance , Inc.

6 And/or its agents to conduct such an investigation and release Priority Ambulance , Inc., including its agents, officers, employee s, agents and representatives from all liability or responsibility for this investigation. I understand that the INFORMATION requested below regarding sex, race and date of birth are for the sole purpose of gathering the above INFORMATION accurately and will not be used to discriminate against me in violation of any law. I understand any initial employment offer will be contingent until all INFORMATION is obtained and processed, including results of a urine drug test, and may be subsequently withdrawn based on the results of these understand that a consumer report may be requested or an investigation conducted. I further understand that if employment is denied in whole or in part because of INFORMATION obtained from a consumer reporting ag ency, I have the right to make a written request within a reasonable period of time to receive INFORMATION about the scope and nature of the investigation.

7 A telephonic facsimile (fax) or a photographic copy of this authorization shall be valid as the BOXES MUST BE COMPLETEDA pplicant s Full Legal Name (PRINT)Social Security NumberMaiden or Any Other Name UsedDriver s License Address(es) Note: e-mail willbe the primary means of communicationwith of BirthSexEmergency ContactNameEmergency Contact Phone Number(s)SignatureDateDRUG & ALCOHOL TESTING POLICY STATEMENT AND CONSENT FORMP riority Ambulance , Inc. is committed to maintaining a safe, productive work environment at all facilities and work sites and to safeguarding all property connected with such employment. The concern for the safety of all Priority Ambulance associates is paramount and the signing of the Drug and Alcohol Testing Consent form , constituting agreement and cooperation with this policy, is required of all p ersons as a condition of employment by Priority Ambulance , is the policy of Priority Ambulance , Inc.

8 Not to retain any individuals who test positive for any illegal drug in their system or use illegal drugs or controlled substances, in any amount, regardless of frequency, without a medically acceptable prescription. Therefore, to rule out the presence of non-prescribed or prohibited dangerous substances in the body, Priority Ambulance , Inc. associates may, consistent with state law, be required to undergo a drug screening test for any or all of the following reasons: Pre-employment purposes Continuation of employment Periodic, announced (routing) testing Randomly to ensure consistency and continuance of policy For cause due to reasonable suspicion by Priority Ambulance , Inc. or its clients Post-accident (work-related injury)In addition, Priority Ambulance , Inc. associates may be required to undergo alcohol screening when there is suspicion of impairment or a critical event (work-related injury, unusual behavior, etc.)

9 I understand that according to Priority Ambulance , Inc., policy, I may be required to submit a sample of my urine and/or other body fluids, tissue or filaments for chemical analysis. I understand that qualified personnel will perform the analysis. I consent freely and voluntarily to this request for a specimen of urine and/or other body fluids, tissue or filaments. I hereby and herewith release Priority Ambulance , Inc. The medical provider obtaining the samples and the laboratory performing the analysis (including its employees, agents and contractors) are not liable whatsoever arising from this request to furnish my urine and/or other body fluids, tissue or filaments, the testing of the sample and decision made concerning my employment based upon the results of the analysis. I understand that any person refusing to take or failing to pass the drug screening test will not be qualified for employment with Priority Ambulance , Inc.

10 Until a negative drug test result can be obtained. Initial testing and confirming tests for positive results are at the expense of Priority Ambulance , Inc. Retesting is at my expense, consistent with state law. I have read the foregoing policy statement and consent form and understand and agree to submit to drug and alcohol testing as part of the terms and conditions of my employment with Priority Ambulance , (print): _____ Social Security #:_____Signature: _____ Date: _____Please read each paragraph carefully and check each box signifying your the Document in the Appropriate Space Provided I hereby certify that I have not knowingly withheld any INFORMATION that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application.