Mineola Volunteer Ambulance Corps Application

EMPLOYMENT TYPE (Check all that apply)

AEMT-Paramedic

AEMT-Critical Care

Advanced EMT

EMT-Basic

Not Certified

PERSONAL INFORMATION

First Name:

Last Name:

Middle Name:

Preferred Name:

Phone Number

Date of Birth:

Social Security Number:

Are you 18 years old or older?

Yes

Current Address:

Address

Additional

City

State

Zip

Previous Address:

(If less than 5 years at your current address.)

Address

Additional

City

State

Zip

MILITARY SERVICE

Are you a veteran?

Yes

Are you a member of the Military Reserves?

Yes

Dates of Military Service:

OTHER INFORMATION

Are you a U.S. Citizen?

Yes

If not, are you eligible to accept permanent employment in this country?

Yes

Visa type:

EDUCATION

Type

School Name

Address

Additional

City

State

Zip

Dates Attended Start

Dates Attended End (Leave Blank if Presently Attending)

Major / Minor

Degree

Did you graduate?

Yes

EMPLOYMENT

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)?

Yes

Company

Dates Start

Dates End (Leave Blank If Currently Employed Here)

Address

Additional

City

State

Zip

Phone Number

Fax Number

Supervisor Name

Supervisor E-Mail

Job Position(s) & Essential Functions

Reason(s) for Leaving (Enter "N/A" If Currently Employed Here)

DRIVING AND BACKGROUND

Drivers License Information:

State

Number

Do you have any moving violations in the last year?

Yes

Explain (Enter "None" If No)

Have you been convicted of Driving Under the Influence (DUI) or any other traffic violations in the last seven years?

Yes

Explain (Enter "None" If No)

Have you ever been convicted of a felony or misdemeanor?

Yes

Explain (Enter "None" If No)

MEDICAL CERTIFICATION

What institution / agency provided your current NYS EMS certification training? (If Applicable)

Agency

Are you approved to practice in New York State?

Yes

Have you ever been reprimanded and / or disciplined by your medical director?

Yes

Explain

Are your continuing education requirements up to date?

Yes

Where have you been receiving your continuing education?

Institution

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

PROFESSIONAL AND CIVIC

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.

VOLUNTEER EXPERIENCE

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

Yes

INTEREST

Why do you want to volunteer for the Mineola Volunteer Ambulance Corp.?

Is there any additional information that you feel would be helpful and/or useful for us to know about you as an applicant?

ACKNOWLEDGEMENTS

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.

REFERENCES

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

Title

Full Name

E-Mail

Phone Number

Alternate Number

Address

Additional

City

State

Zip

Title

Full Name

E-Mail

Phone Number

Alternate Number

Address

Additional

City

State

Zip

Title

Full Name

E-Mail

Phone Number

Alternate Number

Address

Additional

City

State

Zip

AGREEMENT

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.

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER