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Application for Employment


Paramedics and EMTs interested in employment must be at least 21 years of age.

Applicant's Name:  
Address:  
City:  
State, Zip:  ,
Phone:  
Cell Phone:  
Email:  

Position of Interest:  
  Career 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.