| Applicant's Name: | |
| Address: | |
| City: | |
| State, Zip: | , |
| Phone: | |
| Cell Phone: | |
| Email: | |
|
| Position of Interest: | |
| |
Paid
Volunteer |
|
Current
Certification Level: |
EMT-B
EMT-I
EMT-CC
EMT-P |
| Online with REMO: |
Yes
No |
|
| Availability: |
Days
Evenings
Weekends
Part Time
Full Time
|
|
| Have you been employed by or volunteered for Greenport Rescue Squad in the past? |
| |
Yes
No |
| Dates: | |
| Reason for leaving: | |
|
|
| Are you a U.S. Citizen or legal alien authorized to work in the U.S.? (Proof of citizenship or immigration status is required upon employment) |
| |
Yes
No |
|
| Have you ever been convicted of a felony or misdemeanor? (Convictions will not necessarily disqualify an applicant from employment) |
| |
Yes
No |
| If yes, please explain and include dates: | |
|
|
| Are you able to perform the duties/responsibilities for which you are applying? |
| |
Yes
No |
| If accommodations are required, please clarify: |
|
|
|
| Please list all previous employers and provide contact information |
|
| Current Employer: | |
| Address: | |
| Phone Number: | |
| Supervisor's Name: | |
| May we contact for a reference:
Yes
No |
|
| Current/Most Recent Employer: | |
| Address: | |
| Phone Number: | |
| Supervisor's Name: | |
| May we contact for a reference:
Yes
No |
|
| Previous Employer: | |
| Address: | |
| Phone Number: | |
| Supervisor's Name: | |
| May we contact for a reference:
Yes
No |
|
| Previous Employer: | |
| Address: | |
| Phone Number: | |
| Supervisor's Name: | |
| May we contact for a reference:
Yes
No |
|
|
| Please provide complete information for three individuals who are not related to you who
will be able to provide reference information regarding your character and work ethics. |
|
| Name: | |
| Address: | |
| Phone Number: | |
| Cell Number: | |
| Relationship: | |
| Years Acquainted: | |
|
| Name: | |
| Address: | |
| Phone Number: | |
| Cell Number: | |
| Relationship: | |
| Years Acquainted: | |
|
| Name: | |
| Address: | |
| Phone Number: | |
| Cell Number: | |
| Relationship: | |
| Years Acquainted: | |
|
APPLICANT ACKNOWLEDGEMENT
PLEASE READ CAREFULLY BEFORE SUBMITTING |
|
I certify that the information included on the application form, and attached documents, is true and
complete to the best of my knowledge. I am aware that omission of information will be treated as false
statements and such omissions shall be grounds for termination of the interview process or grounds for
dismissal, if employed.
I authorize investigation of all statements contained in the application, attached documents and the
references provided during the application process to give any and all information regarding my previous
employment and any pertinent information they may have, personal or otherwise. I release all parties from
all liability for any damage that may result from furnishing reference information.
I understand and agree, if hired, my employment is at will for no definite period and may be terminated by
me or the company at any time without prior notice, with or without cause. I understand that if hired I am
required to abide by all rules, regulations and policies of Greenport Rescue.
|
|
