Mineola Volunteer Ambulance Corps Application

EMPLOYMENT TYPE (Check all that apply)

Current Address:

Previous Address:

(If less than 5 years at your current address.)
Are you a veteran?
Are you a member of the Military Reserves?
Are you a U.S. Citizen?
If not, are you eligible to accept permanent employment in this country?
Did you graduate?


List below all present and past employers over the past three years, starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.

May we contact your current employer(s)?

Drivers License Information:
Do you have any moving violations in the last year?
Have you been convicted of Driving Under the Influence (DUI) or any other traffic violations in the last seven years?
Have you ever been convicted of a felony or misdemeanor?
What institution / agency provided your current NYS EMS certification training? (If Applicable)
Are you approved to practice in New York State?
Have you ever been reprimanded and / or disciplined by your medical director?
Are your continuing education requirements up to date?
Where have you been receiving your continuing education?

List all emergency services certifications and/or training that you have completed (Even if they are expired.)


List any professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, sexual orientation, national origin, ancestry, age, disability or any other protected status.

Have you ever volunteered for an EMS and/or Fire agency?

Please read each statement closely and check the check box acknowledging your understanding.

Equal Employment Opportunity
This Company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, sexual orientation, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the Company.
Discrimination and Sexual Harassment
This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment; (2) submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.
Drug/Alcohol Testing
If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company.
Complete and Accurate Information
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Testing Authorization
If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.
Investigation Authorization
I authorize investigation into all statements and references contained in this application. I authorize this Company to conduct background checks upon submitting this application. These background checks will include arson history, criminal history, sex offender registry status, driving abstract, and inquiry of all references provided; additional background checks will be conducted as deemed necessary by the department, including post-hire investigations.

Please indicate the names of the persons who will provide your references. The first reference should be your current or most recent supervisor.


I certify that I have given true, accurate and complete information on this application and any supplements. I authorize educational institutions, associations, registration and licensing boards and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand false information or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and/or criminal action. I further understand that dismissal upon employment shall be made mandatory if fraudulent disclosures are given to meet position qualifications, notwithstanding any provision of State or Federal law, I expressly waive any right I may have to review material or information received from a previous employer or educational institution under promise of confidentiality.