Positive Medical

 1-863-655-0030
1-877-605-3204

Job Application

Job Application V2
  1. PERSONAL DATA
  3. 1.Mr/Ms/Mrs(Last Name First Name Middle Name)(*)
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  4. 2.Maiden Name (if applicable)
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  5. 3.Current Address
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  6. 4. Email
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  7. 5. Permanent Address (if different from above)
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  8. 6.Cell Phone
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  9. 7.Business Phone
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  10. 8.DOB(*)
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  11. 9.Place of birth(country _ city _ state)
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  12. 10.U.S. Citizen
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  13. 11. If No, indicate type of visa
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  14. 12.Visa Number
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  15. 13.Have you been naturalized?(*)
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  16. 13.Do you have legal rights to work in the US(*)
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  17. 14.Have you ever had your name legally changed ?(*)
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  18. 15.If you answered Yes to the above question, what was ?
  19. a.Your previous name
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  20. b.Date and location of change
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  21. c.Reason for change
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  22. 15.Have you ever been known by any other name?
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  23. If yes, list all including nicknames, street names, alias:
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  24. 16.Marital Status
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  25. 17. Sex
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  26. Weight(LBS)
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  27. Height (_ft_in)
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  28. 18.Have you ever been convicted of a criminal offense ?
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  29. 19.Social Security Number(*)
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  30. 20.Driver License Number(*)
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  31. State(*)
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  32. CAREER INTEREST
  34. 21.Type of work desired ?
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  35. 22. What position are you applying for ?
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  36. 23. List all relatives or friends currently employed by Positive Mobility Inc. (Name_ Relation)
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  37. 24. Have you ever applied to work for Positive Mobility Inc before ?
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  38. If yes, explain
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  39. 25. Are you now on any eligibility list with any other company
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  40. 26. Have you ever been dismissed, disciplined, or asked to resign because of Misconduct or unsatisfactory service
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  41. If yes, list those employers who dismissed you, disciplined you, or requested that you resign:(Employer Name_Date_Supervisor Involved)
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  42. 27. May we contact previous employers?
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  43. If no, please state reason
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  44. 28. May we contact your present employer in the final stages of processing ?
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  45. If no, please state reason
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  46. 29. Are you on any pain medicines
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  47. EMPLOYMENT RECORD
  49. 22.List all employment. List most recent position first. Include part-time and summer jobs
  50. From
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  51. To
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  53. Name of Employer(*)
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  54. Address(*)
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  55. Phone
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  56. Job Description
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  57. Name of Supervisor
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  58. Salary
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  59. Benefits
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  60. Reason For leaving
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  61. Was any disciplinary action taken against you while employed here?
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  63. From
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  64. To
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  66. Name of Employer(*)
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  67. Address(*)
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  68. Phone
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  69. Job Description
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  70. Name of Supervisor
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  71. Salary
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  72. Benefits
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  73. Reason For leaving
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  74. Was any disciplinary action taken against you while employed here?
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  76. From
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  77. To
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  79. Name of Employer(*)
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  80. Address(*)
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  81. Phone
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  82. Job Description
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  83. Name of Supervisor
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  84. Salary
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  85. Benefits
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  86. Reason For leaving
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  87. Was any disciplinary action taken against you while employed here?
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  89. From
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  90. To
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  92. Name of Employer(*)
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  93. Address(*)
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  94. Phone
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  95. Job Description
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  96. Name of Supervisor
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  97. Salary
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  98. Benefits
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  99. Reason For leaving
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  100. Was any disciplinary action taken against you while employed here?
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  102. From
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  103. To
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  105. Name of Employer(*)
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  106. Address(*)
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  107. Phone
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  108. Job Description
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  109. Name of Supervisor
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  110. Salary
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  111. Benefits
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  112. Reason For leaving
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  113. Was any disciplinary action taken against you while employed here?
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  115. From
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  116. To
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  118. Name of Employer(*)
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  119. Address(*)
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  120. Phone
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  121. Job Description
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  122. Name of Supervisor
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  123. Salary
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  124. Benefits
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  125. Reason For leaving
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  126. Was any disciplinary action taken against you while employed here?
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  127. MARITAL STATUS
  129. 30.
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  130. 31.Name of spouse
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  131. 32. Wife’s maiden name?
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  132. 33. Are you responsible for making child support payments, has legal action been taken Against you for either failing to make payments or delaying payments?
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  133. 34.Amount of child support payments
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  134. 35.Duration of child support payments
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  135. U.S. MILITARY RECORDS
  137. 36.If you have never served in the Armed Forces of the US, sign the following statement, I have never served in any branch of the US Military Service.(If you have ever served in the Armed Forces, attach a copy of your DD-214 form to this application)
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  138. 37.Draft Status
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  139. Reserve Status
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  140. 38.National Guard Status
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  141. 42.Active Service
  142. From
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  143. To
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  144. 39.Branch
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  145. Highest Rank
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  146. 40.Type/Date discharge
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  147. 41. Was any type of disciplinary action ever taken?
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  148. 42.Were you ever the scope of or involved in any criminal or civil investigation while in .The service
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  149. If yes, please explain
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  150. 43.Military Specialization and duties?
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  151. 44. List foreign countries served in or visited in while in the service?
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  152. 45. List all disability applications filed with the Veterans Administration(Date_Claim_Reason_Granted_Yes/No _% of disability)
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  153. 46. Have you ever served in the Armed Forces of any foreign nation
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  154. If yes, indicate nation
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  155. 47. Date of entry
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  156. 48.Date of separation
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  157. ACADEMIC RECORDS
  159. 49. List all relevant schools that you have attended
  160. School
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  161. State/ Country
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  162. From
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  163. To
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  164. Course of study
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  165. Degree/ Certificate received?
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  166. In what
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  168. School
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  169. State/ Country
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  170. From
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  171. To
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  172. Course of study
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  173. Degree/ Certificate received?
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  174. In what
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  176. School
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  177. State/ Country
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  178. From
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  179. To
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  180. Course of study
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  181. Degree/ Certificate received?
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  182. In what
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  184. School
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  185. State/ Country
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  186. From
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  187. To
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  188. Course of study
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  189. Degree/ Certificate received?
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  190. In what
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  191. 50.Please list any suspensions or other disciplinary action taken against you while Attending college or vocational training:
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  192. 51.Please list all honors, awards, scholarships, foreign languages spoken or written
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  194. 55.Do you have any immediate civil actions pending
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  195. 56.Does your spouse have any immediate civil actions pending?
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  196. 57.Have you ever had a judgment rendered against you
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  197. 58.Have you ever been declared delinquent in child support?
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  198. 59.Have you ever been declined a life insurance policy?
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  199. 60.Have you ever been declined an automobile insurance policy?
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  200. 61.Have you ever been declined a health insurance policy?
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  201. 62.Have you ever been bonded?
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  202. 63.Have you ever had a bond refused?
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  203. 64.Have you ever been arrested, received a notice to appear, charged, pled nolo Condere, or pled guilty to any criminal violation, regardless if the record was Sealed or expunged?
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  204. 65.Have you ever had any portions of your criminal record expunged or sealed?
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  205. 66.Have you ever been arrested?
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  206. 67.Have you ever been the subject of or involved in a criminal investigation?
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  207. 68.Has any law enforcement officer ever detained you?
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  208. 69.Have you ever been reported as a missing person
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  209. MOTOR VEHICLE OPERATOR RECORDS
  211. 70.Can you operate a motor vehicle?
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  212. 71.Do you possess a valid driver’s license?
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  213. 72.Drivers license type
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  214. State of issuance
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  215. MOTOR VEHICLE RECORDS
  216. 73.License status?
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  217. 74.Has your driver’s license ever been revoked or suspended?
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  218. If yes please explain on separate sheet
  219. 75.Have you ever been involved in a motor vehicle accident?
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  220. 76.Have you ever been refused a driver’s license?
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  221. If yes, please explain
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  222. 77.Have you ever received a traffic citation?
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  223. 78. Have you ever been charged with DUI?
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  224. REFERENCES
  226. 79.Fill in the names of three people that are not related to you and are not former Employers, whom you have known for at least 5 years
  227. Name
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  228. Home phone
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  229. Home Address
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  230. Year’s known
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  231. Profession
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  233. Name
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  234. Home phone
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  235. Home Address
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  236. Year’s known
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  237. Profession
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  239. Name
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  240. Home phone
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  241. Home Address
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  242. Year’s known
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  243. Profession
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  244. PERSONAL REFERENCE
  246. 80.Please list four personal references you have known and have been in contact with For the past three years
  247. Name
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  248. Home phone
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  249. Home Address
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  250. Year’s known
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  251. Profession
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  253. Name
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  254. Home phone
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  255. Home Address
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  256. Year’s known
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  257. Profession
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  259. Name
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  260. Home phone
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  261. Home Address
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  262. Year’s known
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  263. Profession
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  265. Name
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  266. Home phone
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  267. Home Address
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  268. Year’s known
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  269. Profession
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  271. I affirm that this application contains no misrepresentations or falsifications, omissions, or concealment of material fact and that information given by me is true and complete to the best of my knowledge and belief. I am aware that statements made by me on this application are subject to later investigations. I am further aware that should any investigation disclose any such misrepresentations or falsifications, omissions, or concealment of material fact, my application may be rejected and my name removed from the eligibility lists. If already appointed, I may be dismissed
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  272. ADDITIONAL COMMENTS/ JUSTIFICATION:
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  273. Affidavit of Application
  274. Full Name
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  275. Mailing Address
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  276. Home Phone
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  277. Cell Phone
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  278. Social Security Number
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  279. DOB
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  280. I fully understand that in order to qualify as a Positive Mobility Inc driver, I must fully comply with the provisions below. ____1. Be at least 21 years of age ____2. Be a citizen of the United States ____3. Be a high school graduate or equivalent ____4. Not have been convicted of a felony or false statement ____5. Not been undesirable discharge from any of the Armed Forces of the US ____6. Agree to be finger printed ____7. Pre-employment drug screen ____8. Pass a physical examination ____9. Be of good moral character
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  281. I hereby certify that to the best of my knowledge and belief, the information that i have entered on this form is true and correct.
  282. Clearififation
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  283. Invalid Input
  284. Submit


©2010 Positive Medical Transport

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