PAID STAFFING DIVISION

EMPLOYMENT APPLICATION

* Indicates required field

Name *

First

Last

Date Of Birth *

Age *

Email *

Phone Number *

Cell Phone Carrier *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Social Security Number *

Drivers License Number *

State & Expiration Date *

EMT NUMBER *

EXPIRATION DATE *

CPR EXPIRATION *

ACLS EXPIRATION *

PALS EXPIRATION *

MEDIC NUMBER *

CERTIFICATION INFO & PREVIOUS AGENCY INFORMTAION

Are you currently/previously been involved/employed with another agency? *

YES NO

If the answer is YES, please list here & why you left if not currently there. *

Emergency Contact

Name *

Relation *

Address *

Phone Number *

References

1. Name *

Phone Number *

Known How Long? *

2. Name *

Phone Number *

Known How Long? *

3. Name *

Phone Number *

Known How Long? *

Employment History

1. Name of Employer *

Job Title *

Supervisor *

PHONE NUMBER *

How been employed and reason for leaving (If applicable) *

2. NAME OF EMPLOYER *

JOB TITLE *

SUPERVISOR *

PHONE NUMBER *

How been employed and reason for leaving (If applicable) *

Questionaire

Do you now have any physical, mental, emotional or nervous conditions, diseases or disabilities that may affect your ability to perform duties in this Rescue Squad? *

YES NO

Have you ever been convicted of any crimes at any level? *

YES NO

If YES, please explain: *

Do you have any pending criminal court cases? *

YES NO

Do you have any points on your driving record? *

YES NO

If YES, please explain: *

IF YES, PLEASE EXPLAIN: *

DO YOU POSSESS ANY SKILLS THAT WOULD BENEFIT AND BE HELPFUL TO THIS ORGANIZATION? *

Have you been involved/employed with any other EMS agency? *

YES NO

If the answer is YES, please list here and why you left. *

PLEASE READ CAREFULLY:

Queensbury Emergency Medical Service prides themselves on accepting applications for Volunteering & Paid Staffing regardless of an applicant's race, color, creed, sex, marital status, disability, national origin, ancestry or place of birth.

I hereby apply for Paid Staffing membership in Queensbury EMS Inc. I understand that my acceptance in either of these corporations will be on a six month probationary basis. During which time my status may be terminated in accordance with the corporation by-laws or New York State Labor Laws. Any false statements or omissions made in this application will be considered sufficient cause for expulsion from the corporation upon discovery thereof.

I hereby authorize Queensbury EMS, or its representatives to make official inquiry of all persons, public and private companies, corporations, consumer reporting agencies, law enforcement agencies, state licensing and certifying agencies and medical advisors of this corporations to supply all information concerning my character, current and prior employment or membership verification, general reputation, personal characteristics and mode of living and furnish reports thereon.

If I am accepted as Paid Staff, I will follow the operating rules as adopted and the by-laws as they may be amended in the future. I will agree to submit to physical and medical examinations at the option and expense of the corporation and also agree that the examining physician will disclose to the corporation or its representatives, the results of such examinations.

PLEASE SIGN TO SHOW ACKNOWLEDGEMENT. (You may have to sign a paper form during interview.) *

date of acknowledgement: *

DISCLOSURE & RELEASE

In connection with my application for employment (including contract for services) with Queensbury EMS, I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions and revocations as well as checking the NYS Sex Offenders Registry.

I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION

I have the right to obtain information as to the name, address and phone number of any agency providing such information and further, may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information, as well as, the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request.

This authorization shall remain on file and shall serve as ongoing authorization for the organization to procure Motor Vehicle Reports at any time during my employment, membership or contract period.

PLEASE SIGN TO SHOW ACKNOWLEDGEMENT. (You may have to sign a paper form during interview.) *

date of acknowledgement: *

YOUR CART

EMPLOYMENT APPLICATION

CERTIFICATION INFO & PREVIOUS AGENCY INFORMTAION

Emergency Contact

References

Employment History

Questionaire

PLEASE READ CAREFULLY:

DISCLOSURE & RELEASE

I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION