Employee Application Today’s Date(Required) MM slash DD slash YYYY Name(Required) First Last Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)Email Address(Required) Interested in working:(Required) Full-Time Part-Time Contingent What is your current level of licensure?(Required) EMT Paramedic None Position Applied for(Required) EMT Paramedic Dispatcher Biller/Office Other Salary Desired(Required) Tell us about your current or previous employer and your job title.(Required)Is there anything else you would like to share about yourself?May we contact your current/previous employer for references?(Required) Yes No CERTIFICATION and AUTHORIZATION(Required)Please select the checkbox to agree. I hereby affirm that all information given by me on this application is true. I understand that in the event of my employment by Miles, Grubb & Associates, LLC; DBA Star EMS, any falsification or omission on this application is grounds for immediate termination. I authorize a thorough investigation to be made in connection with this application concerning criminal record, educational background, and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to Miles, Grubb & Associates, LLC; DBA Star EMS and to hold Miles, Grubb & Associates, LLC; DBA Star EMS and any former employer harmless from any claim made on the basis that the information about me was provided or that the employment decision was made on the basis of such information. I authorize Miles, Grubb & Associates, LLC; DBA Star EMS to verify my driving record with the State Department of Motor Vehicles and or the Secretary of State. Any applicant or employee needing accommodation to perform his or her job must notify the Company in writing within 182 days after the need is known. I understand that nothing in this employment application, the granting of an interview, or my subsequent employment with Miles, Grubb & Associates, LLC; DBA Star EMS is intended to create an employment contract between Miles, Grubb & Associates, LLC; DBA Star EMS and myself. I understand and agree that if hired, my employment will be terminable at will and may be terminated by me or Miles, Grubb & Associates, LLC; DBA Star EMS at any time for any or no reason with or without cause or notice of any kind. I understand that no representative of Miles, Grubb & Associates, LLC; DBA Star EMS, other than the President, and in writing, has the authority to enter into any agreement for any specified period of time or to make any agreement contrary to the above. If employed I understand that the Miles, Grubb & Associates, LLC; DBA Star EMS may unilaterally change or revise their benefits, policies, and procedures and such changes may include reduction in benefits. Employee agrees that any controversy arising out of or in connection with employee’s compensation, employment, or termination, including but not limited to any and all claims of discrimination or any kind, shall be submitted to arbitration through the American Arbitration Association (AAA), with arbitration to occur within the State of Michigan at a location of the Company’s choosing, and to be resolved in accordance with the rules then in effect for AAA. The arbitration proceeding will allow the parties to be represented by counsel at their respective expense, reasonable discovery, a hearing on the merits of the claim, selection of a neutral arbitrator by mutual agreement, and if the parties are unable to agree, based on procedures provided by the AAA, judicial review as provided by Michigan law, and a written award containing findings of fact and conclusions of law. The purpose of this Agreement to Arbitrate is to provide Employee and the Company a forum in which claims or disputes with the Company are resolved by arbitration rather than litigation. This does not restrict Employee from filing a claim or charge with any State or Federal Agency. Rather, this Agreement to Arbitrate applies only to State and Federal court proceedings. In consideration of Miles, Grubb & Associates LLC’s review of my application, I agree that any claim or lawsuit arising out of my employment with, or my application of employment with Miles, Grubb & Associates LLC, DBA Star EMS or any of its subsidiaries, include State and Federal Civil Rights actions, must be filed with AAA within six (6) months of the date of the event giving rise to the claim or forever be barred. While I understand the statute of limitations for claims arising out of an employment action may be longer than six (6) months, I agree to be bound by the six (6) month period of limitations set forth herein, and I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY. I hereby acknowledge that I have read, understand, and agree to the above statements. Signature(Required)CAPTCHA Δ
