Please complete the application below and we will be in touch. Complete 0% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Personal Information First Name: Middle Name Last Name Address 1: Address 2: City: State: Zip Code: Email: * Home Phone: +1 Search Date Available to Start: Alt Phone: +1 Search Hours Requested: Full-Time Full-Time Part-Time Part-Time Back Next Save Progress Complete 8% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Position Information Are you at least 21 years of age? Yes Yes No No Dates of prior employment: Have you ever applied or been employed by Mercy Regional EMS before? Yes Yes No No Reason(s) for leaving: Position(s) applying for: Locations Applying For: All Locations All Locations Broken Arrow, OK Broken Arrow, OK Cleveland, OK Cleveland, OK Craig County, OK Craig County, OK Glenpool, OK Glenpool, OK Owasso, OK Owasso, OK Back Next Save Progress Complete 16% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Certification Information Certification Type: Certification Name Expiration Date: Certification Body: CPR EMT/EMT-P National Registry PALS ACLS BTLS EMD CDL Other Back Next Save Progress Complete 25% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 General Information Do you have a valid driver's license? Yes Yes No No License Class: State: Driver's License: List all moving violations (convictions) and accidents and any suspensions or revocations of your license in the last five years: Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, Including a DUI/DWI or similar offense, had any moving violations, or had your license Revoked or suspended? Yes Yes No No Please Explain: Back Next Save Progress Complete 33% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Additional Information How did you find out about this position? Do you have any relatives or friends working here? Yes Yes No No If yes to previous question, please list: Back Next Save Progress Complete 41% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Employment History (List your last three employers starting with the most recent) Employer 1 Employer Name Job Title Supervisor: Start Date: Salary: Ending Date: Salary: Job Description Employer Phone +1 Search Reason for Leaving: Back Next Save Progress Complete 50% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Employment History, continued Employer 2 Employer Name Job Title Supervisor: Start Date: Salary: Ending Date: Salary: Job Description Employer Phone +1 Search Reason for Leaving: Back Next Save Progress Complete 58% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Employment History, continued Employer 3 Employer Name Job Title Supervisor: Start Date: Salary: Ending Date: Salary: Job Description Employer Phone +1 Search Reason for Leaving: Back Next Save Progress Complete 66% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Employment History, continued Employer 4 Employer Name Job Title Supervisor: Start Date: Salary: Ending Date: Salary: Job Description Employer Phone +1 Search Reason for Leaving: Back Next Save Progress Complete 75% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Education and Training High School School Name: Highest Grade Completed: Address 1: Address 2: City: State: College School Name: Highest Degree Achieved Address 1: Address 2: City: State: Technical School School Name: Highest Degree/Certification Achieved Address 1: Address 2: City: State: Other School/Training School Name: Highest Degree/Certification Achieved Address 1: Address 2: City: State: Back Next Save Progress Complete 83% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Professional References List three professional references who have knowledge of your work experience and/or education Reference 1 Name: Relationship: Number of Years Known: Email Address: * Occupation: Phone Number: +1 Search Reference 2 Name: Relationship: Number of Years Known: Email Address: * Occupation: Phone Number: +1 Search Reference 3 Name: Relationship: Number of Years Known: Email Address: * Occupation: Phone Number: +1 Search Personal References List two personal references, other than relatives, that have known you for at least three years outside work Reference 1 Name: Relationship: Number of Years Known: Email Address: * Occupation: Phone Number: +1 Search Reference 2 Name: Relationship: Number of Years Known: Email Address: * Occupation: Phone Number: +1 Search Back Next Save Progress Complete 91% 1 Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 7 Page 7 8 Page 8 9 Page 9 10 Page 10 11 Page 11 12 Page 12 Acknowledgement I certify that the information I have given on this application is trueue, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate Mercy Regional Emergency Health Services in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be “at will” and whether I or Mercy Regional Emergency Health Services is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment. If offered a position at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties. I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by Mercy Regional Emergency Health Services as a condition of my employment, and I hereby give my consent to the release of all information which Mercy Regional Emergency Health Services deems necessary to determine my ability to perform job duties now or in the future. I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from Mercy Regional Emergency Health Services. I hereby authorize Mercy Regional Emergency Health Services to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release Mercy Regional Emergency Health Services and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded; my employment with Mercy Regional Emergency Health Services may be terminated. Accept and Acknowledge: * Accept and Acknowledge: I Acknowledge the above Submit Back Next Save Progress
I certify that the information I have given on this application is trueue, complete and correct, and I understand that any false information, or the omission of information may be considered as sufficient reason for my discharge if hired. I recognize that completion of this application does not mean that job openings exist and does not obligate Mercy Regional Emergency Health Services in any way. Applications will remain active for six months, after which time re-application will be necessary. If hired, employment will be “at will” and whether I or Mercy Regional Emergency Health Services is free to terminate the employment relationship at any time without cause and without prior notice. This application is not an agreement or a contract for employment. If offered a position at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the job duties. I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) prior to employment and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by Mercy Regional Emergency Health Services as a condition of my employment, and I hereby give my consent to the release of all information which Mercy Regional Emergency Health Services deems necessary to determine my ability to perform job duties now or in the future. I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate discharge from Mercy Regional Emergency Health Services. I hereby authorize Mercy Regional Emergency Health Services to investigate my employment history with former employers and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, and other such inquiries. I release Mercy Regional Emergency Health Services and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded; my employment with Mercy Regional Emergency Health Services may be terminated.
