Application for Employment

 * Required Fields

5/11/2008

 Personal Information

Name(First, Middle, Last):*

SSN:*  

Best time to be reached: 

Address:* 

City:*
 

State:*

Zip:*  
 

Phone Number:*
 

Alternate Number:
 

 Referral Source
If referred by an employee, please state name and area:
If referred by an agency, please state agency name:

 Position Desired
Position:

Some positions might require working overtime, weekends, evenings, or holidays, is this acceptable?

Minimum Acceptable Pay :
$
 
Per
Date Available: 

 Eligibility/History
Are you eligible to work in the United States?
Are you at least 18 or older?
Have you ever been convicted of a crime?
If yes, please explain:   
Have you ever been excluded, debarred, suspended, or otherwise determined to be ineligible to participate as a provider or employee or agent of a provider of health care services associated with any federal, state, local, or private health care insurance program (for example, Medicare or Medicaid)?
Have you ever been convicted of, plead to contest to or been the beneficiary of a plea agreement involving a criminal offense charged against you related to health care?
Have you ever been employed by Rural/Metro or any of its subsidiaries?

Please list any relatives in our employ and relationship.  
Do you have a contract or agreement with another company that may limit your ability to perform work for Rural/Metro (e.g., a non-compete or confidentiality agreement)?

 Qualifications

Type of training

Expiration Date
(if any)

Level

Instructing Agency
(if any)

 Certification #
(if any)

EMT

CPR

 

 

 

 

other

 

 

 

 

 Employment Record (Please list 3 employers, most current first. We will be contacting supervisors for references.)

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
  
Salary Start 
$ 		End  
$
PER
May we contact this employer?

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  
 

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
Salary Start  
$   		End  
$
PER
May we contact this employer?

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  
 

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
Salary Start  
$   		End  
$  
PER
May we contact this employer?

 Education - High School

Name:

Location:

Last year completed:
Graduated:

 Education - College/University

Name:

Location:

Last year completed:
Graduated:

 Education - Graduate School

Name:

Location:

Last year completed:
Graduated:

 Professional Courses, etc.

Professional Courses  
 

Special Skills, Trade, Specialized Training, Apprenticeship, Extracurricular Activities  

Acknowledgement of Receipt

Representatives of Rural/Metro Corporation may not enter into an employment agreement for a specified period of time without express written consent of the Company's Chief Executive Officer or his/her designee.

As part of the employment application process at Rural/Metro and for subsequent employment purposes (if you are hired), a consumer report may be obtained. This type of report is generally called a credit or background check and may include information on your credit standing and capacity, character, general reputation, personal characteristics or mode of living. In accordance with the Fair Credit Reporting Act, by signing below you authorize any reference, school, former employer or other person to disclose to Rural/Metro upon request any information to Rural/Metro. Any reports provided to Rural/Metro will not contain medical information.

The information provided in this Application for Employment is true and complete. Rural/Metro may disqualify me from consideration for employment or terminate my employment for any false or misleading statements or omissions in this Application, whenever they may be discovered.

Any offer of employment extended by Rural/Metro is expressly contingent upon: (1) acknowledging receipt of Rural/Metro's Employee Handbook, Person to Person Program, Corporate Compliance Handbook and HIPAA Handbook; (2) passing a pre-employment substance abuse test; and (3) a satisfactory consumer report. Certain positions may have additional pre-employment requirements, which will be discussed with you during the application process.

Rural/Metro Corporation and federal and state laws prohibit discrimination on the basis of race, color, religion, national origin, sex, age, or disability.

I have read and agree to the Acknowledgement of Receipt, and all information provided in this application is accurate and complete.



*Please click the submit button only once. It could take up to 3 minutes to complete your application. You will be transfered to a new page once your application is successfully submitted.