17762 Metzler Lane | Huntington Beach, CA 92647 | 714.847.9107

	Shoreline Ambulance Corp. considers applications for employment without regard to race, color, national origin, ancestry, religion, sex, age, disability, political belief, military service, or any other protected class. Shoreline Ambulance Corp. IS A DRUG-FREE WORKPLACE PERSONAL INFORMATION Name: Email: SSN  -  -  Address: City: State: Zip: Home Phone: Other Phone: Are you at least 18 years of age? Yes No Date Avail to Start: Hours Requested: (Please check one) Full TimePart Time How did you find out about the position? Do you have any relatives or friends working/volunteering here? Yes No If yes, please list. POSITION INFORMATION Position(s) applying for: Have you ever worked/volunteered here? Yes No If yes, please list position(s): Reason(s) for leaving: CERTIFICATION INFORMATION (List only current certifications - photocopies required at interview) CPR EMT EMT-P National Registry PALS ACLS BTLS EMD CDL EMPLOYMENT HISTORY Employer: Employer Phone: May we contact? Job Title: Supervisor: Dates worked: Salary: Job Description: Reason(s) for leaving: Employer: Employer Phone: May we contact? Job Title: Supervisor: Dates worked: Salary: Job Description: Reason(s) for leaving: Employer: Employer Phone: May we contact? Job Title: Supervisor: Dates worked: Salary: Job Description: Reason(s) for leaving: