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Emergency: Schenectady
(518) 374-4401
Emergency: Albany
(518) 434-4151
Emergency: Troy/Brunswick
(518) 274-4888
Business Office
(518) 374-4468

Employment Application


Personal Details  (* indicates required fields)

 
Date:
* First Name:
Middle Name:
* Last Name:
Maiden:
* Are you at least 18 years of age?  
* Are you 21 years of age or older?  
* If not a United States citizen, do you have the legal right to remain permanently and to work in the United States:  
* Address:
* City:
* State:    * Zip:
* Phone:
Cell Phone:
* Email:
 

Tell Us About Yourself

* Position Applying For:      
Billing Office:    
  Other
EMT/AEMT Number:
Expiration Date: Pick a date
Number of Years Active in EMS:
Are you EMD Certified?:  
Do you have a CDL?:  
Other Certifications

Availability

 
  Typical shift change times are 0700 and 1800
Monday:  
Tuesday:  
Wednesday:  
Thursday:  
Friday:  
Saturday:  
Sunday:  
 
Availability Notes:
Employees who work in the Field Operations Division of Mohawk Ambulance Service must perform certain critical functions which include driving a motor vehicle in emergency situations and other physically demanding tasks such as the treatment, lifting and moving, and transporting of the ill and injured.  The New York State Department of Health has issued written functional position descriptions for Emergency Medical Technician – Basic (EMT-B) and Advanced Emergency Medical Technician (AEMT) positions which are available to any job applicant upon request or on the NYS DOH website.  Are you able to satisfy the functional requirements for the position you are applying for, with or without reasonable accommodation?      
* Have you ever worked for us in the past?  
  If Yes - reason for leaving?
 
* Have you ever been convicted of a crime?  

If yes, list all misdemeanors and felonies, including date(s), offense(s) and disposition(s) and the State(s) in which the conviction(s) occurred.  Do not list convictions under a youthful offender status, convictions that have been sealed under New York’s Criminal Procedure Law, or adjournments in contemplation of dismissal.  Please note that a conviction of a crime does not necessarily result in a disqualification from employment.

Motor Vehicle Experience

 
* Do you have a valid drivers license?  
Have you been a licensed driver for more than 3 years?  
Driver’s License Number:
State Licensed In:
* Violations or Accidents?  
  If Yes - specify:
 

Education History

 
High School:
High School Location:
High School Years Completed:
 
College:
College Location:
College Years Completed:
Degree:
 
Other College:
Other College Location:
Degree or Certification Obtained:
 

Current/Previous Employment

 
Company Name (Current Employer):
Address:
City:
State:    
Zip:
Job Title:
Employed from: Pick a date   to   Pick a date
Reason For Leaving:
Supervisor Name:
Phone:
Contact?  
 
Company Name:
Address:
City:
State:   
Zip:
Job Title:
Employed from:  Pick a date   to   Pick a date
Reason For Leaving:
Supervisor Name:
Phone:
Contact?  
 
Company Name:
Address:
City:
State:   
Zip:
Job Title:
Employed from:  Pick a date   to   Pick a date
Reason For Leaving:
Supervisor Name:
Phone:
Contact?  
 

Personal References

 
Reference 1  
* Name:
* Phone:
Address:
City:
State:    Zip:
 
Reference 2  
* Name:
* Phone:
Address:
City:
State:    Zip:
 
Reference 3  
* Name:
* Phone:
Address:
City:
State:    Zip:
If referred by an MAS employee, please specify who:
 
PLEASE READ CAREFULLY

I authorize investigation of all statements contained in this application and affirm that they are true and complete to the best of my knowledge.  I understand that the misrepresentation or omission of facts called for is cause for immediate dismissal at any time without previous notice.  I hereby give permission to contact schools, previous employers (unless otherwise indicated), references and others and hereby release Parkland Ambulance Service, Inc. and any persons who respond to its inquiry from any and all liability as a result of such investigations.

 

I also understand that (1) Parkland Ambulance Service, Inc. is a drug free employer having a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of periodic and random testing under such policy.

 

I agree to take a physical examination prior to employment and at any time at the request of Parkland Ambulance Service, Inc. and at no personal expense to me, and agree that the examining physician or their representative may disclose the findings to the company or an authorized agent of the company.

 

Parkland Ambulance Service, Inc. is an equal employment opportunity employer.  We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability.  We assure you that your opportunity for employment with this company depends solely on your qualifications.

 

I agree that all the information provided above is correct:  

Date:

Human Verification Image:  
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