P.O. Box 776
209 E. Lake St.
Silver Lake, WI 53170

(262) 889-8093

“Providing Emergency Medical Services
Since 1959”

Printable Application

Silver Lake Rescue Squad Inc.
P.O. Box 776
Silver Lake, WI 53170

APPLICATION FOR EMPLOYMENT

DATE_________________

PERSONAL INFORMATION

NAME__________________________________________________________

ADDRESS_______________________________________________________

CITY______________________STATE____________ZIP______________

ARE YOU AT LEAST 18 YRS OF AGE _________YES ________ NO

HOME PHONE____________________ALT. PHONE__________________

SOCIAL SECURITY NUMBER_____________________________

DRIVERS LICENSE NUMBER_____________________________

POSITION APPLIED FOR: Emergency Medical Technician

EDUCATION:

HIGH SCHOOL__________________________________________________

CITY______________________________STATE_______________________

DID YOU GRADUATE? YES________ NO__________

COLLEGE_________________________________________

CITY_________________________STATE______________

SUBJECT STUDIED______________________________________________

DID YOU GRADUATE? YES________NO___________

SPECIAL TRAINING: ____________________________________________

______________________________________________________________

EMPLOYMENT:

CURRENT EMPLOYER___________________________________________

ADDRESS_______________________________________________________

POSITION_______________________________________________________

FROM __________________ TO ________________

LAST EMPLOYER_______________________________________________

ADDRESS______________________________________________________

POSITION______________________________________________________

FROM __________________ TO ________________

LICENSE INFORMATION:

EMERGENCY MEDICAL TECHNICIAN

WISCONSIN STATE LICENSE NUMBER ____________________________

NATIONAL REGISTRY NUMBER__________________________________

REFERENCES: (personal or employment)

NAME__________________________________________________________

ADDRESS_______________________________________________________

PHONE___________________________ YEARS KNOWN_______________

NAME__________________________________________________________

ADDRESS_______________________________________________________
PHONE___________________________ YEARS KNOWN_______________

NAME__________________________________________________________

ADDRESS_______________________________________________________

PHONE___________________________ YEARS KNOWN_______________

AUTHORIZATION

I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE CONSIDERED GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.

I UNDERSTAND THAT I WILL BE REQUIRED TO PASS A PHYSICAL EXAMINATION, INCLUDING A DRUG TEST BEFORE A FINAL OFFER OF EMPLOYMENT IS MADE. BY SIGNING MY NAME BELOW I CONSENT TO THESE PROCEDURES.

I UNDERSTAND THAT I AM RESPONSIBLE FOR REIMBURSING SILVER LAKE RESCUE SQUAD FOR ANY CLASSES NOT PASSED OR COMPLETED.

SIGNATURE:_______________________________ DATE:_______________

PLEASE RETURN APPLICATIONS IN PERSON TO:

SILVER LAKE RESCUE BUILDING
OR
MAIL TO:
P.O. BOX 776
SILVER LAKE, WI. 53170

www.csilverlakeres@wi.rr.com