Employment Application

Reliance Medical Transport Is an Equal Opportunity Employer. Thank you for your interest in applying with Reliance Medical Transport. Please fill out this application as completely as you can. We will need a copy of your driver's license and all your applicable certifications for this job. We also require a sled check which can be done online. Upon your successful interview please bring a voided check to orientation.

Reliance Medical Transport Location you are applying for *

Name *

Todays Date: *

Address *

City *

State *

Zip Code *

Phone Number: *

Alternate Phone:

Driver License State and Number *

Date of Birth: (Must be at least 21 years of age to drive) *

Email Address *

Desired Position *

SC Certification Number

Are You Currently Employed? *

May We Contact your Current Employer? *

Shift Desired *

Social Security Number *

Wage/Salary Request: *

Date Available To Begin: *

High School Name *

High School Location *

Last Grade Completed *

Diploma/Certificate/GED *

Vocational, Technical, College, University, Or Other

Location

Major

Degree

Have you ever been employeed by an Agape Senior entity *

If yes, which Agape Senior entity

Reason for seperation from previous Agape Senior employment:

If employment was under another name, provide the name used:

Have you ever been discharged by an employee? *

If "Yes" please provide the date, reason, and employer name and phone number:

Have you ever been convicted of a felony? *

Have you ever been sanctioned or reprimanded in any way by a goverment body related to healthcare(DHEC, DHHS, OIG, etc.). Convicted of a criminal offense related to healthcare, or listed by a federal agency as debarred, excluded, or otherwise ineligable for participation in a federal funded healthcare program? *

If you answered "Yes" to one or both of the questions above, please list all prior convictions/sanctions with their date of issue:

Employer Name & Title of immediate supervisor *

Start Date *

End Date: *

Starting Salary: *

Ending Salary: *

Your Position Or Title *

Your Duties and Responsibilities *

Company phone Number:

Company Address:

Reason for leaving *

Employer Name & Title of immediate supervisor

Start Date

End Date:

Starting Salary:

Ending Salary:

Your Position Or Title

Your Duties and Responsibilities

Company phone Number:

Company Address:

Reason for leaving

Employer Name & Title of immediate supervisor

Start Date

End Date:

Starting Salary:

Ending Salary:

Your Position Or Title

Your Duties and Responsibilities

Company phone Number:

Company Address:

Reason for leaving

Attach your Resume (Optional)

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Employment Application