Applicants are considered without regard to race, religion, gender, national origin, age, disability, marital, veteran, or any other legally protected status. Please type or print and provide complete answers. If you feel that any question may violate your rights, do not answer it.

Date of application: On what date will you be available to begin working?
Position you are applying for: (check one) Full-Time Part-Time Per Diem

Last Name: First Name: M.I.

Street Address: City: State: Zip Code:
Driver's license number: State:
E-mail: Telephone: Other number(s) you can be reached at:
What is your schedule preference? (check one) Days Evenings Nights   
Are you available on weekends?
Will you work any shift?

Have you ever been convicted of a crime? Yes No   if yes, please explain:

Have you ever applied for employment with MedStar? Yes No      Did someone refer you to MedStar? Yes No

Emergency Medical Certifications:

EMT# Level: (check all that apply)	Basic   Mast   SAED   Epi Pen   Paramedic Assistant
	Intermediate
	Paramedic
	Other:

High School

Name and location of high school:
Course of study: Number of years completed: Did you graduate? Yes No

College

Name and location of college:
Course of study: Number of years completed: Did you graduate? Yes No

Trade School / Other

Name and location of school:
Course of study: Number of years completed: Did you graduate? Yes No

Please list all employers, past and present, starting with the most recent. Attach additional pages if necessary.

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Starting pay $. per  Ending pay $. per Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Starting pay $. per  Ending pay $. per Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Starting pay $. per  Ending pay $. per Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Starting pay $. per  Ending pay $. per Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Starting pay $. per  Ending pay $. per Dates of employment Starting: Ending:
Reason for leaving:

List professional, trade, or civic activities and offices held:

Provide any additional information which you feel may be helpful to MedStar in considering your application. You may also include any hobbies / interests:

References

Please list three or more people who are not related to you who you have known for at least one year. (These people may be contacted by MedStar.)

Name and Address	Phone Number	Occupation