Online Application

Thank you for your interest in joining Northern Virginia's premier medical transportation agency. This is the first part of the application process and you will be required to provide written verification of EMS certification(s) and license information after submission. A member of Human Resources will be contacting you for more information and to schedule a pre-hire screening.

Personal Information
Enter your information into the fields provided. Fields marked with an
asterisk (*) are required to continue.
 
First Name: *
Middle Initial:
Last Name: *
E-Mail Address:
Home Address: *
 
City: *
State: *
ZIP: * (99999-9999)
Home Phone: * (999-999-9999 x999)
Other Phone:   (999-999-9999 x999)
Best method to contact you: *
Position applying for: *
Preferred schedule: *
Available start date: *  (yyyy-mm-dd)
How did you hear about us? *
Legally authorized to work
in the U.S.?		 YesNo *

Certificates & Licenses
Enter all that apply to your requested position.
 
  Number: State: Expires: (yyyy-mm-dd)
Driver's License:
 
  Number: Level: Expires: (yyyy-mm-dd)
National Registry:
 
  Number: Level: Expires: (yyyy-mm-dd)
State Certification:
  State/Jurisdiction:
 

Other Certifications
Enter all that apply to your requested position.
 
  Certification: Expires: (yyyy-mm-dd)
CPR-Health Care Provider
CPR-Instructor
EVOC (VA required)
ACLS
PALS
PHTLS
 
  Certification Name: Expires: (yyyy-mm-dd)
Other
Other
Other
Other

Employment History
Please list your employers starting with the most recent, covering up to the last seven (7) years of employment.
 
Company 1:
Name of Company:
Address:
 
City:
State:
ZIP:
Phone Number:  (999-999-9999 x999)
Begin Date:  (yyyy-mm-dd)
End Date:  (yyyy-mm-dd)
Position Held:
Beginning Salary:
Ending Salary:
Duties:
Name of Supervisor:
May we contact? YesNo
Reason for leaving?
 
Company 2:
Name of Company:
Address:
 
City:
State:
ZIP:
Phone Number:  (999-999-9999 x999)
Begin Date:  (yyyy-mm-dd)
End Date:  (yyyy-mm-dd)
Position Held:
Beginning Salary:
Ending Salary:
Duties:
Name of Supervisor:
May we contact? YesNo
Reason for leaving?
 
Company 3:
Name of Company:
Address:
 
City:
State:
ZIP:
Phone Number:  (999-999-9999 x999)
Begin Date:  (yyyy-mm-dd)
End Date:  (yyyy-mm-dd)
Position Held:
Beginning Salary:
Ending Salary:
Duties:
Name of Supervisor:
May we contact? YesNo
Reason for leaving?
 
Company 4:
Name of Company:
Address:
 
City:
State:
ZIP:
Phone Number:  (999-999-9999 x999)
Begin Date:  (yyyy-mm-dd)
End Date:  (yyyy-mm-dd)
Position Held:
Beginning Salary:
Ending Salary:
Duties:
Name of Supervisor:
May we contact? YesNo
Reason for leaving?

Education
High School:
Name of School: *
City: *
State:
Did You Graduate? YesNo *
Degree Earned:
 
College or Vocational School 1:
Name of School Attended:
City:
State:
Major:
Did You Graduate? YesNo
Degree Earned:
 
College or Vocational School 2:
Name of School Attended:
City:
State:
Major:
Did You Graduate? YesNo
Degree Earned:
 
College or Vocational School 3:
Name of School Attended:
City:
State:
Major:
Did You Graduate? YesNo
Degree Earned:

Disclaimer

By submitting this on-line application, you attest that all information submitted is correct and accurate to the best of your knowledge. Any falsification, misrepresentation, or ommission of information may cause denial of employment or termination from employment.

All employment offers are contingent upon successful completion of pre-hire screening. This includes but is not limited to a background investigation, prior employment verification(s), verification of driving record and EMS certification(s).

Clicking the submit button below indicates my legal submission of my employment application to Loudoun-Fairfax Ambulance, I have read and agree to the terms above.

Loudoun-Fairfax Ambulance is an Equal Opportunity Employer (EOE). Qualified applicants are considered for employment without regard to age, race, color, religion, sex, or national origin.