Chesapeake Medical Transport, LLC was formed in 2017, to provide quality medical and mobility transportation in the Southern Maryland Region. 

Chesapeake prides itself on providing prompt and professional care for our patients and clients. 

Chesapeake offers: Advanced Life Support, Basic Life Support and Wheelchair/Mobility services throughout the State of Maryland.    

Employment Application

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APPLICANT INFORMATION
Last Name:
First Name:
Middle Initial:
Street Address:
City, State, Zip Code:
Email Address:
Social Security Number:
Date of Birth:
Home Phone:
Cell Phone:
Are you a US Citizen?:		Select Below Yes No
Authorized to work in US?:		Select Below Yes No
Position Desired:		Select Below First Responder / Driver EMT-B / Attendant EMT-B / Driver EMT-I - / CRT EMT-P / Paramedic
Hours Requested: Select all that apply		Full Time Part Time PRN
Date Available:
Desired Salary:
EMPLOYMENT QUESTIONS
Have you ever been Employed at Chesapeake Medical Transport Services before:		Select Below Yes No
If Yes, List Dates:
Do you have any friends or relatives that work at Chesapeake Medical Transport Services?:		Select Below Yes No
If Yes, Who?:
Have you ever been convicted of a crime? :		Select Below Yes No
If Yes, Explain:
Do you have any physical, mental, or medical impairments which may limit your ability to perform job related duties?:		Select Below Yes No
If Yes, Please explain:
How did you hear about Chesapeake Medical Transport Services?:
CERTIFICATIONS / LICENSES
Currently an NREMT?:		Select Below Yes No
PSC License?:		Select Below Yes No
Do you have EVOC?:		Select Below Yes No
CDL License?:		Select Below Yes No
Highest level of Medical Certification:		Select Below 1st Responder EMT-Basic EMT-Intermediate EMT-Paramedic None
Certification #1: List Certification Type, State and Certification #
Certification #2: List Certification Type, State and Certification #
Certification #3: List Certification Type, State and Certification #
Driver's License #:
State Issued:		Select Below Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY
Do you have points on your driving record?:		Select Below Yes No
If so, how many? :		Select Below 1 2 3 4 5 6 7 8 9 10 11 12 13 14+
EDUCATION
High School attended :
High School Location (City/State):
Did you graduate or receive a GED?:		Select Below Yes No
Date graduated, or received GED:
Higher Education #1: College or University, Location (City/State), Dates attended and Major or Degree awarded
Higher Education #2: College or University, Location (City/State), Dates attended and Major or Degree awarded
Higher Education #3: College or University, Location (City/State), Dates attended and Major or Degree awarded
PERSONAL REFERENCES
Reference #1: Full Name, Occupation, Address, City, State, Zip, Relationship, Home Phone, Cell Phone,Email
Reference #2: Full Name, Occupation, Address, City, State, Zip, Relationship, Home Phone, Cell Phone,Email
Reference #3: Full Name, Occupation, Address, City, State, Zip, Relationship, Home Phone, Cell Phone, Email
EMPLOYMENT HISTORY
Company Name - Employer #1:
Address - Employer #1:
Supervisor - Employer #1:
Phone Number - Employer #1:
Job Title - Employer #1:
Salary - Employer #1:
Dates Employed - Employer #1:
Reason for leaving - Employer #1:
Company Name - Employer #2:
Address - Employer #2:
Supervisor - Employer #2:
Phone Number - Employer #2:
Job Title - Employer #2:
Salary - Employer #2:
Dates Employed - Employer #2:
Reason for leaving - Employer #2:
Company Name - Employer #3:
Address - Employer #3:
Supervisor - Employer #3:
Phone Number - Employer #3:
Job Title - Employer #3:
Salary - Employer #3:
Dates Employed - Employer #3:
Reason for Leaving - Employer #3:
VOLUNTARY DISCLOSURE:		Accept Voluntary Disclosure Decline Voluntary Disclosure