Amerimed EMS Online Application Form Name Email Phone Number Address STATUS AND ELIGIBILITY If applying for field EMT position, are you 21 years or older? YesNo Are you a citizen of the U.S. or do you have the legal right to be employed in the U.S. YesNo Have you ever been convicted of any crime (excluding minor traffic violations)other than what was listed on previous page? YesNo If yes, please state the offense, location, date and disposition: Do you have the physical ability to move and/or lift as required by the job for which you are applying? YesNo If No, please explain your limitations Do you have the ability to work overtime if it is required by the job for which you are applying? YesNo If no, please explain LOCATION DESIRED Please indicte your preferred work location: North GeorgiaMiddle GeorgiaSouth GeorgiaEastern TennesseeMiddle TennesseeWestern TennesseeNorthern MississippiOhioIndianaSouth Carolina EMPLOYMENT INFORMATION Full-TimePart-TimeTemporary Date available to start By clicking "Submit" I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form or during any subsequent forms and/or during any interviews may be grounds for my immediate dismissal.