Lifeline healthcare Solutions
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LifeLine Employment Application

Tell Us About Yourself-all fields with an * are required
A name is required. A name is required.
An address is required.
A value is required. A value is required. A value is required.
An email is required.
An email is required.The emails don't match.
A phone # is required. Cell Phone:
National Certification:          
New Hampshire Provider Number:
State:*
Please make a selection.
Please make a selection.
Please make a selection.
Career Interests

        
     
A date is required.
Education
GED:
  
EMS Employment History
Reason for Leaving:
Non EMS Employment History
Candidate Source * You must tell us how you found out about Lifeline Ambulance.
Employee Referral |
On Line Job Posting | Name of Job Board:   
| Instructor's Name:  

Representation of Data:

I hereby represent that all information entered above on my application for employment is true and accurate.  I understand that if I am hired based upon my representations and any of these representations are determined false, the company may terminate my employment at any time.

Electronic Signature: A value is required.

Driving Record:

I understand that any future decision for employment may be based upon my driving history.  I agree to procure and provide a copy of my driving record from the Motor Vehicle Department in the State where issued and submit the certified copy to LifeLine at the time of my interview. 

Electronic Signature: A value is required.

Criminal History:

I understand that any future decision for employment may be based upon my criminal history.  Therefore, I authorize LifeLine Ambulance Service to perform a Criminal History Records Check on myself as a condition of my employment and authorize the company to perform these checks annually.

Electronic Signature: A value is required.

LIFELINE AMBULANCE SERVICE            |            Servicing New England