pdf - Priority Ambulance

APPLICATION FOR EMPLOYMENT
PLEASE READ CAREFULLY. PLEASE PRINT IN BLACK INK OR TYPE IN
APPLICABLE SPACES. ANY OMISSION OF INFORMATION (EXCEPT AS NOTED
BELOW) WILL INVALIDATE YOUR APPLICATION FROM CONSIDERATION.
PERSONAL INFORMATION
LAST NAME
FIRST NAME
ADDRESS
APT. NO.
ARE YOU UNDER 21 YRS. OF AGE?
NO
CITY
POSITION APPLYING FOR:
HAVE YOU APPLIED WITH KUNKEL
AMBULANCE, INC BEFORE?
IF YES, STATE AGE:
NO
SALARY/HOURLY WAGE DESIRED:
IF YES, WHEN:
DATE AVAILABLE:
INDICATE SHIFT NEED/PREFERENCE:
9-HR M-F
11-HR
DID YOU LEARN OF THE POSITION FROM AN EXISTING OR FORMER KUNKEL
YES
NO
IF YES, EMPLOYEE NAME:____________________________________________
AMBULANCE, INC. EMPLOYEE?
ARE YOU RELATED IN ANY WAY TO THIS EMPLOYEE?:
EDUCATION
YES
NO
S C H O O L N A M E, A D D R E S S & T E L E P H O N E
12-HR
AVAILABILITY:
DAY / NIGHT
24 HR:
A
B
St
Zip
Phone
St
Zip
Phone
C
FULL-TIIME
P/T- PRN
USA CITIZENSHIP STATUS:
UNITED STATES CITIZEN
NON-CITIZEN: Permanent Resident Alien Registration No.:
NON-CITIZEN: Visa Number and Expiration Date:
CAN YOU PROVIDE LEGAL PROOF OF ELIGIBILITY TO WORK IN THE U.S.? YES
FROM
TO
GRADUATED
DIPLOMA
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
High School or Highest Grade Completed
City
PHONE
ZIP
STATE
DEGREEType
COURSES
Major
NO
GRADE
AVG.
HS Diploma
GED
College or University
City
Professional or Technical School
City
St
Zip
Phone
L I C E N S E S / C E R T I F I C A T I O N S – Submit copies of all cards.
PROFESSIONAL LICENSE OR
CERTIFICATION
CERTIFICATION NUMBER
ISSUANCE DATE
EMT-P
EMT
EMT-I
Paramedic
EXPIRATION
DATE
INSTRUCTOR?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
EMPLOYMENT HISTORY
EMPLOYER
TELEPHONE
DATE EMPLOYED
FROM:
TO:
ADDRESS:
JOB TITLE:
STARTING HOURLY RATE/SALARY:
FINAL HOURLY RATE/SALARY:
$
$
SUMMARIZE THE NATURE OF THE WORK PERFORMED AND JOB RESPONSIBILITIES:
IMMEDIATE SUPERVISOR & TITLE:
TELEPHONE NO.:
MAY WE CONTACT THIS EMPLOYER:
YES / NO
REASON FOR LEAVING:
EMPLOYER
TELEPHONE
DATE EMPLOYED
FROM:
TO:
ADDRESS:
JOB TITLE:
STARTING HOURLY RATE/SALARY:
FINAL HOURLY RATE/SALARY:
$
$
SUMMARIZE THE NATURE OF THE WORK PERFORMED AND JOB RESPONSIBILITIES:
IMMEDIATE SUPERVISOR & TITLE:
TELEPHONE NO.:
MAY WE CONTACT THIS EMPLOYER:
YES / NO
REASON FOR LEAVING:
EMPLOYER
TELEPHONE
DATE EMPLOYED
FROM:
TO:
ADDRESS:
JOB TITLE:
STARTING HOURLY RATE/SALARY:
FINAL HOURLY RATE/SALARY:
$
$
SUMMARIZE THE NATURE OF THE WORK PERFORMED AND JOB RESPONSIBILITIES:
IMMEDIATE SUPERVISOR & TITLE:
TELEPHONE NO.:
MAY WE CONTACT THIS EMPLOYER:
YES / NO
REASON FOR LEAVING:
REFERENCES – PROFESSIONAL
List at least 2 professional references.
PROFESSIONAL REFERENCE 1 – NAME
TELEPHONE
PROFESSIONAL REFERENCE 2 – NAME
TELEPHONE
PROFESSIONAL REFERENCE 3 – NAME
TELEPHONE
REFERENCES – PERSONAL
List at least 3 personal references not related to you.
PERSONAL REFERENCE 1 – NAME
TELEPHONE
HOW DO YOU KNOW THIS PERSON?
PERSONAL REFERENCE 2 – NAME
TELEPHONE
HOW DO YOU KNOW THIS PERSON?
PERSONAL REFERENCE 3 – NAME
TELEPHONE
HOW DO YOU KNOW THIS PERSON?
CRIMINAL CONVICTIONS
Have you, within the last seven years, been convicted of or pleaded guilty or nolo contendere (no contest) to a
felony crime? (Convictions that have been expunged, sealed or legally eradicated need not be listed.) Check One
YES
NO
If YES, state the nature of the crime(s), when and where convicted and the disposition of the case. A conviction will not necessarily disqualify you from
employment. The nature of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may be considered.
Can you perform the essential functions of this job, with or without reasonable accommodation? Check
YES
NO
Can you meet the attendance requirements of this job? Check
YES
NO
If hired, I will provide proof of my legal authorization to work in the United States.
CRIMINAL INVESTIGATION CONSENT
I, __________________________________________, hereby authorize Kunkel Ambulance, Inc. to receive
and share any criminal history record information, with prospective employers pertaining to me which may be in the
files of any state or local criminal justice agency in New York.
Date:
Signature
I hereby state that the information given by me in my employment application is true and complete in all
respects. I understand that in consideration of my application, an investigation may be conducted of my past
employment and activities. I authorize past employers, personal references and any other persons with
whom I am acquainted to answer all questions asked concerning my previous employment record, ability,
military service, educational background, medical history, criminal record history, credit history, driving
record, workers’ compensation claims, character and reputation. I release all persons, including past
employers, credit bureaus and government agencies, from any liabilities or damages on account of having
furnished such information in good faith.
In consideration of my application, I authorize Kunkel Ambulance, Inc. and/or its agents to conduct such
an investigation and release Kunkel Ambulance, Inc., including its agents, officers, employees, agents
and representatives, from all liability or responsibility for this investigation. I understand that the
information requested below regarding sex, race and date of birth are for the sole purpose of
gathering the above information accurately and will not be used to discriminate against me in violation of
any law. I understand any initial employment offer will be contingent until all information is obtained
and processed, including results of a urine drug test, and may be subsequently withdrawn based on the
results of these investigations.
I understand that a consumer report may be requested or an investigation conducted. I further understand
that if employment is denied in whole or in part because of information obtained from a consumer reporting
agency, I have the right to make a written request within a reasonable period of time to receive information
about the scope and nature of the investigation. A telephonic facsimile (fax) or a photographic copy of this
authorization shall be as valid as the original.
ALL BOXES MUST BE COMPLETED
Applicant’s Full Legal Name (PRINT)
Social Security Number
Maiden or Any Other Name Used
Driver’s License No./State Issued
Email Address(es) –Note: email will be the primary means of communication with you.
Date of Birth
Sex
Emergency Contact Name
Emergency Contact Phone Number(s)
Signature
Date
DRUG & ALCOHOL TESTING POLICY STATEMENT AND CONSENT FORM
Kunkel Ambulance, Inc. is committed to maintaining a safe, productive work environment at all
facilities and worksites and to safeguarding all property connected with such employment. The concern
for the safety of all Kunkel Ambulance associates is paramount and the signing of the Drug and Alcohol
Testing Consent Form, constituting agreement and cooperation with this policy, is required of all
persons as a condition of employment by Kunkel Ambulance, Inc.
It is the policy of Kunkel Ambulance, Inc. not to retain any individuals who test positive for any
illegal drug in their system or use illegal drugs or controlled substances, in any amount, regardless of
frequency, without a medically acceptable prescription. Therefore, to rule out the presence of nonprescribed or prohibited dangerous substances in the body, Kunkel Ambulance, Inc. associates
may, consistent with state law, be required to undergo a drug screening test for any or all of the
following reasons:






Pre-employment purposes
Continuation of employment
Periodic, announced (routine) testing
Randomly to ensure consistency and continuance of policy
For cause due to reasonable suspicion by Kunkel Ambulance, Inc. or its clients
Post-accident (work-related injury)
In addition, Kunkel Ambulance, Inc. associates may be required to undergo alcohol screening
when there is suspicion of impairment or a critical event (work-related injury, unusual behavior, etc.).
I understand that according to Kunkel Ambulance, Inc., policy, I may be required to submit a sample
of my urine and/or other body fluids, tissue or filaments for chemical analysis. I understand that
qualified personnel will perform the analysis.
I consent freely and voluntarily to this request for a specimen of urine and/or other body fluids, tissue
or filaments. I hereby and herewith release Kunkel Ambulance, Inc. The medical provide r
obtaining the samples and the laboratory performing the analysis (including its employees, agents
and contractors) are not liable whatsoever arising from this request to furnish my urine and/or other
body fluids, tissue or filaments, the testing of the sample and decision made concerning my
employment based upon the results of the analysis.
I understand that any person refusing to take or failing to pass the drug–screening test will not be
qualified for employment with Kunkel Ambulance, Inc. until a negative drug test result can be obtained.
Initial testing and confirming tests for positive results are at the expense of Kunkel Ambulance, Inc.
Retesting is at my expense, consistent with state law.
I have read the foregoing policy statement and consent form and understand and agree to submit to
drug and alcohol testing as part of the terms and conditions of my employment with Kunkel
Ambulance, Inc.
Name (print): __________________________________ Social Security #:__________________
Signature: ____________________________________ Date: ____________________________
Please read each paragraph carefully and check each box signifying your authorization.
Sign the Document in the Appropriate Space Provided
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, the undersigned applicant, have personally completed this application. I understand that any omission or
misstatement of material fact on this application or on any 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.
I hereby authorize Kunkel Ambulance, Inc. to thoroughly investigate my references, work record, education,
personal & professional references and other matters related to my suitability for employment. Further, I authorize
the references I have listed to disclose to Kunkel Ambulance, Inc. all letters, reports and other information
related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Kunkel
Ambulance, Inc., my former employers and other persons, corporations, partnerships and associations from any
and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application or conveyed during any interview, which may be granted, or
during my employment, if hired, is intended to create an employment contract between Kunkel Ambulance Inc.
and me. In addition, I understand and agree that if I am employed, my employment is at will and is for no definite or
determinable period and may be terminated at any time, with or without prior notice, or with or without cause, at the
option of either myself or Kunkel Ambulance, Inc., and that no promises or representations contrary
to the foregoing are binding on Kunkel Ambulance, Inc., unless made in writing and signed by me and
Kunkel Ambulance, Inc.’s designated representative.
I understand that, in connection with my application for employment, Kunkel Ambulance, Inc. may obtain a
consumer report and/or investigate consumer reports about me that may contain information as to my character,
general reputation, personal characteristics and mode of living. Such reports may include or consist of my d r i v i n g
history obtained from the the appropriate state Department of Motor Vehicles. I further understand that any job
offer extended by Kunkel Ambulance, Inc. is contingent upon receipt of a favorable consumer or
investigative consumer report about me.
I understand that, in connection with my application for employment, depending upon the position for which I have
applied, any offer of employment is conditioned upon my taking and passing a pre-employment drug test and, if
necessary for the position for which I have applied, a pre-employment medical examination and/or physical agility
test. I understand that I may refuse to take any required pre-employment drug test or medical examination, but if
I do, any offer of employment will be immediately withdrawn.
I HAVE READ THE ABOVE PARAGRAPHS, UNDERSTAND THEIR IMPORTANCE AND
EFFECT UPON MY EMPLOYMENT AND ACCEPT SAME AS CONDITIONS OF MY
EMPLOYMENT WITH KUNKEL AMBULANCE, INC.
This application, when completed and signed, becomes the property
of Kunkel Ambulance, Inc.
Applicant Signature: ___________________________________ Date: __________
PRINT NAME: _________________________________________