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Personal Information
If you have the qualifications we seek and are ready to apply for employment with Brewster Ambulance Service, complete this Application for Employment.
Applicant's Name *
Applicant's Name
Applicant's Address
Applicant's Address
Applicant's Phone *
Applicant's Phone
Have you ever been excluded or are currently excluded from participation in any federal or state health program? *
Job Information
Select the hours you desire to work *
Select the location(s) you are able to work *
Check the shift(s) you can work *
Can you provide proof, if hired, that you are eligible to work in the U.S.? *
You are required to have a valid driver's license to apply for employment at Brewster Ambulance Service.
Certification Information
List only current certifications and be prepared to present copies of your certifications at your interview.
Has your license, certification or credentials ever been revoked or put on probation? *
List the expiration date on your currently active licenses/certifications (where applicable)
CPR expiration date
CPR expiration date
BTLS expiration date
BTLS expiration date
ACLS expiration date
ACLS expiration date
PALS expiration date
PALS expiration date
NALS expiration date
NALS expiration date
NREMT expiration date
NREMT expiration date
EMD expiration date
EMD expiration date
Applicant's Work Experience
List work experience starting with your most recent employment. Please bring a copy of your resume to your interview.
May we contact your present employer?
Phone of present employer
Phone of present employer
Present employment supervisor's phone
Present employment supervisor's phone
Employment History #2 - Phone
Employment History #2 - Phone
Employment History #2 - Supervisor's phone
Employment History #2 - Supervisor's phone
Employment History #3 - Phone
Employment History #3 - Phone
Employment History #3 - Supervisor's phone
Employment History #3 - Supervisor's phone
As either an employee or volunteer, have you ever been:
Disciplined or terminated for a driving-related reason? *
Disciplined or terminated for excessive absenteeism? *
Disciplined or terminated for insubordination? *
Disciplined or terminated for harassment or discrimination? *
Disciplined or terminated for alcohol or drug-related reasons? *
Disciplined or terminated for your treatment of a patient? *
Applicant's Education
Graduated high school
Graduated college
Graduated trade/professional
References
Personal and professional (other than relatives)
Reference #1 Phone
Reference #1 Phone
Reference #2 Phone
Reference #2 Phone
Reference #3 Phone
Reference #3 Phone
Disclaimer
I certify that the information I have given on this application is true, complete and correct, and I understand that any false information or the omission of information may be considered as sufficient reason for denial of employment or termination of employment if I become an employee. I recognize that completion of this Application does not mean that I will be accepted as an employee and does not obligate Brewster Ambulance Service to accept me as an employee. Applications will remain active for six months, after which time re-application will be necessary. If accepted for employment, I agree to abide by all rules, regulations and policies established by Brewster Ambulance Service and its managers and other persons in charge. I understand that, if accepted as an employee, my employment is at-will, which means either Brewster Ambulance Service or I can terminate employment for any reason or no reason. This Application is not an agreement or contract for employment. If offered a position and at any time thereafter, I consent to medical examinations as may be required to determine my fitness to perform the duties of my then-current position with Brewster Ambulance Service. I understand that I may be required to undergo drug screening tests as a condition of employment. To comply with this requirement, I consent to providing a sample of my urine or other physical samples (such as blood or hair) after I am offered the position and prior to the start date of my position and again at any time so requested. Specimens will be tested for both legal (prescription drugs) and illegal substances. A positive test for legal substances will require proof of a current prescription. I further consent to allow any doctor, hospital or testing laboratory to conduct any medical test or examination as may be required by Brewster Ambulance Service as a condition of my employment, and I hereby give my consent to the release of all information which Brewster Ambulance Service deems necessary to determine my ability to perform the essential duties of my position now or in the future. I further understand that refusal to submit to an alcohol or drug screen test at any time will result in immediate termination of my employment with Brewster Ambulance Service. I hereby authorize Brewster Ambulance Service to investigate my employment/volunteer history with former employers and volunteer organizations and to make any further investigation deemed necessary in connection with my application for employment, including a criminal history check, driving history check, child abuse clearance check, elder abuse clearance check, FBI background check, and other such inquiries. I release Brewster Ambulance Service and all informants from all liability resulting from such inquiries. I waive all rights to see or review the information so furnished. I agree to immediately notify (within 24 hours) Brewster Ambulance Service of any instance in which I am arrested or convicted of any felony or misdemeanor, or if my driver’s license is suspended or revoked. Failure to notify Brewster Ambulance will result in a immediate termination and the inability to be re-hired. I certify that I am not now, nor have I ever been excluded from any state or federal health care program. I further understand that if it is determined that I was so excluded; my position with Brewster Ambulance Service may be terminated. I agree to immediately notify (within 24 hours) Brewster Ambulance Service if I learn that I am being excluded from participation in any federal or state health care programs.
By typing your full name here, you are digitally signing this application and have agreed to the above disclaimer
Date application is submitted and signed *
Date application is submitted and signed