Joachim-Plattin Ambulance District Employment Application

1235 N.Truman Blvd
Crystal city, MO 63019

Date Date / MM / DD YYYY
Name Name First Last
Position Applied For
Type of employment desired

Type of employment desired Full Time Part Time
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Social Security Number
Phone Phone - ### - ### ####
Email address for communication purposes

Please answer the following questions
Please answer the following questions	Yes	No
Do you have a current State EMS License?	Do you have a current State EMS License?Yes	Do you have a current State EMS License?No
Are you Nationally Registered?	Are you Nationally Registered?Yes	Are you Nationally Registered?No
Are you legally entitled to work in the US?	Are you legally entitled to work in the US?Yes	Are you legally entitled to work in the US?No
Do you have a valid drivers license?	Do you have a valid drivers license?Yes	Do you have a valid drivers license?No

EMS License Number
Education
High School attended and location
Highest grade successfully completed
Year Graduated
University/College attended with location/address
Number of years completed
Year graduated
Degrees completed
Major subjects of specialization
EMT training: List name of training entity year graduated.
Have you attended Paramedic training? If so, list training entity and year attended.
Technical Education

ACLS, ITLS, PALS, CPR
Please list all certifications: Month and year of expiration, Location of course
List additional training programs that you have completed
Driving Experience
Have you ever driven an emergency vehicle? If so, what type and for how long?
State DMV licensed
Drivers license number
Has you license ever been suspended or revoked? If so, when and what for?
List traffic offense citation, including: date, place and disposition for the last 5 years.
List any other traffic offense citation, including: date, place and disposition in the last 5 years.
List any accidents for which you were cited in the last 5 years
If any of the questions under driving are answered yes, please describe the events and conclusion in full.
Legal Issues
List any criminal offenses that you have been convicted of, including date, place and disposition
Have you ever had a judgment against you in a medical malpractice suit?
EMS Skill Summary

Indicate which of the following skills you have performed in the past year
Multiple Choice

Multiple Choice Airway: Oral/Nasal Airway: Combi Tube Airway: Endotracheal Airway: Drug Assisted Intubation (RSI) Ambulance Driving Bag/Valve/Mask Bleeding Control Blood Pressure Burn Management CPR Cardiac Arrest: ACLS Cardioversion Chest Decompression Childbirth Choking Management Decontamination Difibrillation Basic EKG Interpretation 12 Lead Interpretation External Pacing Extrication Fracture Management Blood Glucose IV Establishment IV Blood Draw Medication Administration Oxygen Administration Spinal Immobilization Splinting Stair Chair Ambulance Stretcher Suction Triage Traction Splint Ventilator

Joachim-Plattin Ambulance District Employment Application

Joachim-Plattin Ambulance District Employment Application

Education

Technical Education

Driving Experience

Legal Issues

EMS Skill Summary