Apply for Physician - Disaster Response

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Physician - Disaster Response
ID:2410
Pafford EMS:Offsite/Remote
Division/Department:Operations
State:Offsite/Remote
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Application for Employment
PERSONAL INFORMATION
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):
Yes   No
* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):
Yes   No
* Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last seven years? (A conviction will not necessarily result in the denial of employment):
Yes   No
If Yes, please explain:
* Have you ever worked for this Company before?:
Yes   No
If Yes, please provide details (Where/When/Job Title):
* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:
Yes   No
If no, please explain:

EMPLOYMENT DESIRED
* When would you be available to begin work?:
* Type of employment desired:
Full-Time
Part Time
Seasonal
* Hourly rate/salary desired:
* Are you currently employed?:
Yes   No
If so may we inquire of your present employer?:
Yes   No
If presently employed, why are you considering leaving?:

EDUCATION
Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location Did you Graduate? Degree Received Subjects Studied/Major
Yes   No
Yes   No
Yes   No

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY
Give your full employment record, starting with your current or most recent employment

EMPLOYER 1

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 2

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 3

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

REFERENCES Please provide three references (not relatives).

Name Relationship Phone Number Email

AUTHORIZATION
The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
* Date:
Paramedic - Disaster Relief
* List all states in which you hold an active Paramedic credential
* Do you have an active National Registry Paramedic certification
Yes
No
* Are you available to work in an austere environment for an extended period of time?
Yes
No
How many years have you been credentialed as a Paramedic?
* Describe your past experience, including 911, interfacility, hospital, and/or military experience
Do you have any previous deployment experience? If so, please describe.
* Please select all certifications which you actively hold:
BLS
ACLS
PALS
PHTLS, ITLS, or similar trauma certification
Critical Care Paramedic (CCP-C or CCEMTP)
Flight Paramedic (FP-C)
Community Paramedic (CP-C)
Hazardous Materials Awareness
NIMS ICS 100
NIMS ICS 200
NIMS ICS 300
NIMS ICS 700
NIMS ICS 800
Do you hold any additional certifications?
Please attach a copy of your most recent resume
* Please attach a copy of your Drivers License
* Please attach your Paramedic Certifications
* Please attach copies of your NIMS and Hazardous Materials Awareness Certifications
Attach additional documents as needed
Physician - Disaster Relief
* List all states in which you hold an active, unrestricted license to practice medine
* Are you available to work in an austere environment for an extended period of time?
Yes
No
* Briefly describe your past experience and/or formal training as it relates to disaster medical services
Do you have any previous deployment experience? If so, please describe.
* Please select all certifications which you actively hold:
BLS
ACLS
PALS
ATLS
Hazardous Materials Awareness
NIMS ICS 100
NIMS ICS 200
NIMS ICS 300
NIMS ICS 700
NIMS ICS 800
Do you hold any additional certifications?
Please attach a copy of your most recent resume
* Please attach a copy of your Drivers License
* Please attach copies of your NIMS and Hazardous Materials Awareness Certifications
Attach additional documents as needed
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond

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