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Applicant Information

Applicant Name:*

Telephone Number:

Email Address:

Date of Application:

Employment Position

Position(s) applying for: EMT /Driver ( part time)

How did you hear about this position?

What days are you available for work?

What hours or shift are you available for work?

If needed, are you available to work overtime?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Personal Information

Have you ever applied to or worked for Brockport Volunteer Ambulance Corps before?

Yes

No

If yes, when?

Do you have any friends, relatives, or acquaintances working for Brockport Volunteer Ambulance Corps

Yes

No

If yes, state name & relationship:

Are you 18 years of age or older?

Yes

No

Are you a U.S. citizen or approved to work in the United States?

Yes

No

What document can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

Yes

No

Do you have any condition which would require job accommodations?

Yes

No

If yes, please describe accommodations required below:*

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

No

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:*

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Brockport Volunteer Ambulance Corps complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )

Education and Training

High School: Name, Location (City, State), Year Graduated, Degree Earned

College/University: Name, Location (City, State), Year Graduated, Degree Earned

Vocational School/Specialized Training: Name, Location (City, State), Year Graduated, Degree Earned

Military:

Are you a member of the Armed Services?

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

Previous Employment

Employer Name:

Job Title:

Supervisor Name:

Employer Telephone:

Dates Employed:

Reason for leaving:

Add another employment?

Yes

No

Employer Name:*

Job Title:*

Supervisor Name:*

Employer Telephone:*

Dates Employed:*

Reason for leaving:*

Add another employment?

Yes

No

Employer Name:*

Job Title:*

Supervisor Name:*

Employer Telephone:*

Dates Employed:*

Reason for leaving:*

References

Please provide 2 personal and professional reference(s) below: Reference / Contact Information

Additional Information:

Do you have a current valid NY EMT card?

Do you have a current AHA BLS CPR card?

Social Security Number

Drivers License number and Expiration:

AT-WILL EMPLOYMENT

The relationship between you and the Brockport Volunteer Ambulance Corps is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Brockport Volunteer Ambulance Corps . No representative of Brockport Volunteer Ambulance Corps has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature:

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