Name (First and Last):
Cell Phone Number:
E-mail Address:
Address:
Are you eligible to work in the United States? YesNo
Preferred Method of Contact: Cell PhoneEmail
__________________________________________________________________________________________________________________________
Level of EMT Certification: EMR - Emergency Medical ResponderEMT-B - Emergency Medical TechnicianEMT-P - Paramedic
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) #:
__________________________________________________________________________________________________________________
Employer Name:
Phone Number:
Brief Description of Responsibilities:
Have you worked for Tilton before? YesNo
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, letter of reprimand, letter of clinical deficiency, advisory letter? YesNo
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, commission of any statement, and / or any attempt to misrepresent the truth will result in immediate termination