Personal Information:
Name (First and Last):
Cell Phone Number:
E-mail Address:
Address:
__________________________________________________________________________________
General Information:
Are you eligible to work in the United States?
Preferred Method of Contact:
__________________________________________________________________________________________________________________________
EMS Credential Information:
Level of EMT Certification:
What EMS System are you currently in?:
Illinois Department of Public Health Certifications Number:
Expiration Date:
Basic CPR #: Expiration Date:
Advanced Cardiac Life Support (Paramedics Only) #:
Expiration Date:
__________________________________________________________________________________________________________________
Employment History:
Employer Name:
Phone Number:
Brief Description of Responsibilities:
Have you worked for Tilton before?
Has the Illinois Department of Public Health ever suspended, revoked, or refused to renew your EMT license or taken any other type of disciplinary action against you / or your EMT license including, but not limited to, a letter of reprimand, a letter of clinical deficiency, or advisory letter?
Is there anything else you'd like us to know?
I represent that I have fully understood the questions above, that my answers are truthful and accurate, and that the omission of any material fact, a commission of any statement, and/or any attempt to misrepresent the truth will result in immediate termination
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