WELCOME to SPARTANBURG ems

Please fill out and submit the below form

Have you ever been employed with Spartanburg Regional Healthcare System

Name

Please include your Middle Initial

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

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Social Security Number

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Cell Phone

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Cell Phone Carrier

Alternate Phone

Home Phone or alternate number

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Personal Email

Hospital Email

Certification Type

State EMT ID #

SRHS Employee #

Driver's License Number

State of Driver's License

Driver's License Expiration Date

YYYY

Shift Assignment

Emergency Contact Name

Emergency Contact Phone #

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