Online Application

Personal Information
Name*
First Middle Last
Date of Birth*
Age*
Address*
Street Address Address Line 2 City State ZIP Code
Is this your permanent address?*
- Yes
- No
Referred by
Were you referred by an employee of Life Force?
Email*
Primary Phone*
Secondary Phone

Application
Position applying for*
Type of employment desired*
Approximately how many hours a week are you available
Date you can start*
MM slash DD slash YYYY
Desired hourly wage*
Have you applied to Life Force before?*
- Yes
- No
If so, when?
Have you worked for Life Force before?*
- Yes
- No
If so, when?

Do you have your EVOC, EMSVOC or equivalent certification*
- Yes
- No
Primary Certification
Primary Certification Type*
Primary Certification Number
Primary Certification Expiration Date
MM slash DD slash YYYY
Other Certifications
Health Care Provider CPR - Expiration Date
MM slash DD slash YYYY
Basic Trauma Life Support BTLS - Expiration Date
MM slash DD slash YYYY
Advanced Trauma Life Support ATLS - Expiration Date
MM slash DD slash YYYY
Basic Cardiovascular Life Support BCLS - Expiration Date
MM slash DD slash YYYY
Advanced Cardiovascular Life Support ACLS - Expiration Date
MM slash DD slash YYYY
Pediatric Emergency Assessment, Recognition and Stabilization PEARS - Expiration Date
MM slash DD slash YYYY
Pediatric Advanced Life Support PALS - Expiration Date
MM slash DD slash YYYY
List any other certifications you may hold

High School
High School*
Location*
Years attended*
Subject Studied
Did you graduate?*
- Yes
- No
College
College
Location
Years attended
Subject Studied
Did you graduate?
- Yes
- No
Trade, Business or Correspondence School
School Name
Location
Years attended
Subject Studied
Did you graduate?
- Yes
- No

Reference 1*
Name Title Phone Years known
Reference 2*
Name Title Phone Years known
Reference 3*
Name Title Phone Years known
Terms

I certify the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed by Life Force of Western PA, any falsified statements on this application shall be grounds for dismissal.

I authorize Life Force of Western PA to investigate all statements contained herein and the references and employers listed above to give Life Force of Western PA any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Life Force of Western PA from any liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of Life Force of Western PA has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative of Life Force of Western PA.

I also understand that I may be required to fill out a paper application for my records should I be employed by Life Force of Western PA.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
Digital Signature*
By entering my full name below I understand that; I am digitally signing this application for employment and acknowledge that I have read and understand the above term.
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Online Application

Step 1 of 6

Personal Information

Application

Primary Certification

Other Certifications

Current or most recent employer

Second most recent employer

Third most recent employer

High School

College

Trade, Business or Correspondence School

Terms