Full name (including middle initial)

Valid TN DL number

TENESSEE EMS license number:

License type:

EMT Basic
Advanced EMT
Paramedic
Critical Care Paramedic

Type of emergency vehicle operations course?

Type of employment you are seeking:

Full-time
Part-time

Current Address - Including street address, city, state and zip.

Primary Phone Number (Please denote mobile or home)

Email Address

Other degrees, certs, or licenses

Have you ever worked for this company?

Yes
No

If yes, when?

Please provide two references, their phone numbers and your relationship

Previous employment #1

Previous employment #2

Military service: list branch, dates and type of discharge

User Agreement

DISCLAIMER and SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I authorize all schools, persons and organizations named in this application to provide any relevant information in their possession or knowledge to the agents of MHEMS for the use in their decision to offer me employment and specifically waive any required written notification.  I hereby release MHEMS, my former employers and all other persons from all claims, demands, or liabilities arising out of or in any way related to such inquiry or disclosure.

I understand that MHEMS is committed to maintaining a drug/alcohol free workplace, and I am subject to pre-employment drug/alcohol screening. I further understand that if employed, I may be subject to screening if MHEMS has reasonable suspicion to believe that I am under the influence of drugs or alcohol.  I also understand that I will be subject to random drug and alcohol screening.  My consent to submit to such screening is required as a condition of employment and my refusal to consent shall result in a refusal to hire or, if already employed, termination.

I understand and agree that the employment for which I am making application is, and intended to be, at-will and such employment may be terminated at any time with or without cause, without prior notice, by either myself or MHEMS.  There will be no agreement, express or implied between MHEMS and me for any specific period nor continuing or long-term employment, unless made in writing, signed by an authorized representative of MHEMS.

I acknowledge I have carefully read and understanding the statements listed above.