AMBULANCE

1000 Battles St., Leominister, MA 01453
62 Washington St., Worcester, MA 01608
PHONE (978) 466-1444
FAX (978) 534-9650

Applicants are considered without regard to race, color, national origin, ancestry, age, gender, sexual orientation, religion, disability, military status, genetic information, criminal record, or any other legally protected status. Please type or print and provide complete answers. If you feel that any question or request may violate your rights, do not answer it.

Date of application: On what date will you be available to begin working?
Position you are applying for: (check one) Full-Time Part-Time Per Diem

Information
Last Name: First Name: M.I.

Street Address: City: State: Zip Code:
Driver's license number: State:
E-mail: Telephone: Other number(s) you can be reached at:
What is your schedule preference? (check one) Days Evenings Nights   
Are you available on weekends?
Will you work any shift?

Have you ever applied for employment with MedStar? Yes No      Did someone refer you to MedStar? Yes No
if Yes, Who?

Education

High School

Name and location of high school:
Course of study: Number of years completed: Did you graduate? Yes No

College

Name and location of college:
Course of study: Number of years completed: Did you graduate? Yes No

Trade School / Other

Name and location of school:
Course of study: Number of years completed: Did you graduate? Yes No

Emergency Medical Certifications:

EMT# State: Level: (check all that apply) Basic   Intermediate   Paramedic
Other:

Employers
Please list all employers, past and present, starting with the most recent. Attach additional pages if necessary.

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Additional
List professional, trade, or civic activities and offices held:

Provide any additional information which you feel may be helpful to MedStar in considering your application. You may also include any hobbies / interests:

References

Please list three or more people who are not related to you who you have known for at least one year. (These people may be contacted by MedStar.)

Name and AddressPhone NumberOccupation

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

I hereby certify that the information provided herein is true and complete to the best of my knowledge. I understand that any false statement or deliberate omission of fact is justification for refusal to offer employment and is justification for termination if already employed. I grant permission to MedStar Ambulance, Inc., and its agents to investigate all data provided, and release from liability all persons providing reference information as well as MedStar Ambulance, Inc., and its agents. I understand that any offer of employment will be conditional upon my successful completion of a physical examination, as well as satisfactory references and my presentation of the required documents which provide proof of my eligibility for employment with MedStar. I understand that if I am employed by MedStar, such employment will be on an introductory basis. I understand that such employment is not for any stated time, and may be terminated at any time by myself or MedStar for any reason. If employed, I also agree to understand and abide by the policies and procedures and the employee handbook of MedStar Ambulance. I understand that I may be required to work at times in addition to my regular shift as needed. I authorize MedStar to release reference information with regard to myself without liability. I hereby certify that the information provided herein is true and complete to the best of my knowledge, and agree to the terms and conditions set forth herein.

Signature of Applicant Date