TLC Ambulance

Date of Application:


I am a (EMT,EMT-I,EMT-P.LP,CCEMT/P):


I am applying for
(full time, part time/full time, PRN Position):



I. Personal Information:
*Note: This information is used only to facilitate a background check:

Name:

Social Security Number:

Street Address:

City:

State/Province:

Zip Code:

Home Phone:

Cell Phone:

Email:

Are You Under the Age of 21? [Yes/No]




Texas LifeLine Corporation.complies fully with the "Immigration Reform and Control Act". This act requires that we obtain documents which prove an employee's identity and eligibility to work in the U.S. If hired, can you provide such documents? [Yes/No]


Have you ever been employed by TLC before? [Yes/No]




If yes, list dates and & position:


Current Class C Texas Drivers Licence Number:

Expiration Date:


Do you read, write, or speak any foreign language fluently? [Yes/No]



If yes, which language?


Read
Write
Speak

Do you have any relatives that are currently employed by or have worked for TLC?
Yes No

Relative's Name:

When:


What exactly encouraged you to seek employment with TLC Ambulance?


Did anyone in particular refer you to TLC Ambulance?
Yes No

Who:


Is TLC the only EMS provider with which you applied?
Yes No

Which EMS provider(s) are we.competing with to employ you?


Have you ever been known by any other name other than the one given in this application?
Yes No

Please list all aliases in the spaces provided below:



II. Emergency Contact Information:
Name:

Relationship:

Address:

City:

State/Province:

Home Phone:

Cell Phone:

Pirmary Care Physician:

MD/DO Phone:


III. Military Service:
Check if none.

Branch of Service:

From:

To:

Highest Rank Achieved:

MOS:


Where you discharged from military service with anything other than an Honorable Discharge?
Yes No

Are you currently serving in the Armed Forces Reserve or National Reserve?
Yes No

Current Rank:

MOS:


Do you have a copy of your current drill schedule including any tentative active duty assignments?
Yes No

ETS Date:


IV. Criminal History:
Notice: Texas LifeLine Corporation (TLC Ambulance) is authorized by the city of Dallas to provide private ambulance service upon its public streets and to its citizens under the Dallas City Code, sec. 15D relating to the provision of private emergency ambulance service. As such, the city of Dallas, throuch the Department of Transportation Regulation, also requires all EMS personnel employed by Texas LifeLine Corporation to be permitted as well as work withing the city of Dallas. The Dallas Police Department performs all background checks for the City of Dallas utilizing both the NCIC/TCIC criminal reporting system. You answers to the fololowing questions are required and will help TLC determine whether or not you can be permitted, thus ensuring employment with Texas LifeLine Corporation. Please utilize the addendum located within this application should you require additional writing space in order to.complete any of your answers. You must reference all answers by question number if the addendum is utilized.

Have you ever been convicted of a felony or misdemeanor resulting in jail or prision time?
Yes No

If yes, in the space below you must disclose the date and details of your conviction including punishment:


Are you currently on probation or on parole?
Yes No

If yes, please provide the name and telephone of your probation officer:


Have you ever been convicted of being in possession of or under the influence of an illegal drug?
Yes No

If yes, in the space below, you must disclose the date and details of your conviction including punishment:


V. Driving History:
Texas Drivers License Number:

Class:

Expiration:

How many years have you been a licensed driver?

In which state?

How many years of driving experience do you have?

Emergency Response Vehicle?

Professionally?
Yes No
Volunteer?
Yes No Other

(1) Have you recieved any Emergency Response Vehicle driver training?
Yes No


If yes, in the space below, you must disclose the type(s) of emergency vechile(s) in which you have recieved training:


Course Name:

Where:

Date of completion:

Instructors Name:

Phone:

(2) Have you ever had your drivers privileges revoked?
Yes No

If yes, in the space below, you must disclose all details concerning the revocation or suspension including where, when and how long your privileges where revoked or suspended:



(4) Please list below any moving violations that you have recieved during the past 5 years. Please include the date and location of each offense:


(5) Please list below any motor vechile collisions that you were involved as a driver during the past 5 years. Include details as to the cause of the collision, who was faulted in the collision, where the collision occurred and the date of each:


VI. EMS Training:
Basic EMS Training: (Must be.completed by all applicants)

Where did you complete your Basic-EMT training?:

Course Coordinator:

Instructor:

When did you complete your Basic EMT training?:


Are you currently Texas Department of State Health Services certified?
Yes No

When will your TDSHS certification expire?:

Are you currently Nationally Registered?
Yes No

Registration Number:

When will your National Registry expire?:


Are you currently in Paramedic school?
Yes No

Where:

When will the course begin?:


When will you graduate?:

Instructor:


What is the course schedule?:
Weekday
Weeknight
2X
3X
Shift
A
B
C

Additional Basic EMS Certifications:
CPR Provider
Expiration Date:

ACLS
Expiration Date:

BTLS
Expiration Date:

PHTLS
Expiration Date:

PALS
Expiration Date:

PEPP
Expiration Date:


Advanced EMS Training (complete this section if ALS trained):

EMT-I

Course Location:

Completion Date:

Instructor:

Phone Number:


EMT-P

Course Location:

Completion Date:

Instructor:

Phone Number:


I am a TDSHS:
Certified
Licensed
Nationally Registered Paramedic

Number:


Are you CCEMT/P certified?
Yes No

Course Sponsor:

Instructor:

Curriculum Used:

Completion Date:


Do you have a course completion certificate?
Yes No

Additional Basic EMS Certifications:
CPR Provider
Expiration Date:

ACLS
Expiration Date:

ACLS-EP
Expiration Date:

BTLS/PHTLS
Expiration Date:

Pedi-BTLS
Expiration Date:

Vehicle Access BTLS
Expiration Date:

PPPC/PALS/APLS
Expiration Date:

Flight Paramedic
Expiration Date:

PEPP ALS
Expiration Date:

PEPP BLS
Expiration Date:

ABLS
Expiration Date:

PHBLS
Expiration Date:

Traumatic Brain
Expiration Date:

Injury
Expiration Date:

AMLS
Expiration Date:


Related Advanced EMS Training:
VENT. TRAINING
Instructor:

Location:

Date:


LIFE PAK 12
Instructor:

Location:

Date:


BIPHASIC
Instructor:

Location:

Date:

w/capnograph
Instructor:

Location:

Date:

w/ETCO2
Instructor:

Location:

Date:

w/AED
Instructor:

Location:

Date:

w/pacing
Instructor:

Location:

Date:

w/SPO2
Instructor:

Location:

Date:

w/12 Lead
Instructor:

Location:

Date:

w/NIBP
Instructor:

Location:

Date:

IABP
Instructor:

Location:

Date:

comBI-TUBE
Instructor:

Location:

Date:

BOUJIE
Instructor:

Location:

Date:

KING AIRWAY
Instructor:

Location:

Date:

*** Not having the ability to check any of the above does not qualify or disqualify any applicant. This information is used solely to determine what orientation/training will be required upon employment.


VII. EMS Recertification:
When will your EMT-Basic certification expire?

Expiration Date:

When will your EMT-Intermediate expire?

Expiration Date:

When will your EMT-Paramedic expire?

Expiration Date:

When will your National Registry expire?

Expiration Date:

How many hours of documented CE do you currently have?

Expiration Date:

How many CE hours do you need in order to recertify?

Expiration Date:


VIII. EMS Related Work Experience:
Most Recent Provider:

From:

To:

Address:

Telephone number:

Supervisor:

Position:


Did you provide:(Check all that apply)
Routine Transportation Service:
Yes No

Routine Patient Transfer Service:
Yes
No
BLS
ALS
MICU
CCT

Non Emergency Ambulance Service:
Yes
No
BLS
ALS
MICU
911 Primary:
Yes
No
BLS
ALS
MICU
911 Back-Up for:

Yes
No
BLS
ALS
MICU
What shift did you work? 8 hrs
9 hr
10 hr
12 hr
14 hr
16 hr
24/48
What was your hourly rate of pay for that shift?

Where you paid overtime for all hours worked in excess of 40 hours in any work week?
Yes No
If you answered no, how were you paid?


Are you still employed?
Yes No
Reason for leaving this provider:


Are you required to give notice to this provider?
Yes No
How much?

May we contact?
Yes No
Prior Provider:

From:

To:

Address:

Telephone Number:

Supervisor:

Position:


Did you provide:(Check all that apply)
Routine Transportation Service:
Yes No

Routine Patient Transfer Service:
Yes
No
BLS
ALS
MICU
CCT

Non Emergency Ambulance Service:
Yes
No
BLS
ALS
MICU

911 Primary:
Yes
No
BLS
ALS
MICU

911 Back-Up for:

Yes
No
BLS
ALS
MICU

What shift did you work?
8 hrs
9 hr
10 hr
12 hr
14 hr
16 hr
24/48

What was your hourly rate of pay for that shift?

Where you paid overtime for all hours worked in excess of 40 hours in any work week?
Yes No

If you answered no, how were you paid?


Why did you leave this provider?


Quit with notice.
Abandoned your position.
Terminated
Please Explain?


May We Contact?
Yes No
Prior Provider:

From:

To:

Address:

Telephone Number:

Supervisor:

Position:


Did you provide:(Check all that apply)
Routine Transportation Service:
Yes No

Routine Patient Transfer Service:
Yes
No
BLS
ALS
MICU
CCT

Non Emergency Ambulance Service:
Yes
No
BLS
ALS
MICU

911 Primary:
Yes
No
BLS
ALS
MICU

911 Back-Up for:

Yes
No
BLS
ALS
MICU

What shift did you work?
8 hrs
9 hr
10 hr
12 hr
14 hr
16 hr
24/48

What was your hourly rate of pay for that shift?

Where you paid overtime for all hours worked in excess of 40 hours in any work week?
Yes No

If you answered no, how were you paid?


Why did you leave this provider?


Quit with notice.
Abandoned your position.
Terminated

Please Explain?


May We Contact?
Yes No

IX. EMS Equipment Experience:
Are you experienced with and proficient in the proper use of any of the following EMS equipment?
(check all that apply)****The inability to check any of the following does not disqualify the applicant from employment. The information will be solely used to determine the orientation/training needed for employment.

Mulit-Level H Frame Stretcher
Manufacture:

Model:


Mulit-Level X Frame Stretcher
Manufacture:

Model:


Power Assisted Lift Stretcher
Manufacture:

Model:

Stair Chair
Scoop Stretcher
Folding Auxiliary Stretcher
Wheeled Auxiliary Stretcher
Long Spine Board
KED
Traction Splint:
Hare
Ferno
Sager

Which AED do you presently utilize??
Manufacture:

Model:


Which heart monitor/defibrillator do you presently utilize??
Manufacture:

Model:

Biphasic
monophasic
Don't Know

Do you have a current City of Dallas ambulance permit?
Yes No

Have you ever had a City of Dallas ambulance permit?
Yes No

Have you ever had your city permit suspended or revoked?
Yes No

Have you everbeen party to a lawsuit involving negligence, gross negligence, medical malfeasance, or as a result of collision involving you as the driver of an Emergency Response Vehicle?
Yes No

If you answered yes, explain the circumstances involved and the ou.come of the lawsuit if permitted:


X. General Work Experience:

Company:

From:

To:

Hourly Rate:

Address:

Telephone number:

Supervisor:

Position:

Duties Performed:

Reason For Leaving:


Company:

From:

To:

Hourly Rate:

Address:

Telephone number:

Supervisor:

Position:

Duties Performed:

Reason For Leaving:


Company:

From:

To:

Hourly Rate:

Address:

Telephone number:

Supervisor:

Position:


Duties Performed:

Reason For Leaving:


Company:

From:

To:

Hourly Rate:

Address:

Telephone number:

Supervisor:

Position:

Duties Performed:

Reason For Leaving:


XI. Education(other than EMS Training):

High School Attended:

City/State:

To:

GED?
Yes No

Last Grade Attended:

College Attended:

City/State:

Major:

Minor:


Did you graduate?
Yes No

Hours.completed:

When will you graduate?:


XII. References (Personal/Professional Other Than Relatives):

Name:

Relationship:

Occupation:

Telephone number:


Name:

Relationship:

Occupation:

Telephone number:


Name:

Relationship:

Occupation:

Telephone number:


Name:


Relationship:

Occupation:

Telephone number:


XIII. Volunteer Experience: (Please include Fire Service as wel as EMS):

Department:

City/State/Zip:

Occupation:

Chief:


How long have you been associated with this department?:

Position Held:


Are you still associated with this department?
Yes No

If you answered yes, do you feel as though there may be conflict of intrest between this department and TLC if employed?
Yes No

How many hours a week do you participate with this department?: