Employment Application

We appreciate the opportunity to review your qualifications for employment with this company. So that we can thoroughly consider your special skills and abilities, we would appreciate your completion of our Employment Application. Thank You Beauport Ambulance Service, Inc. is an equal opportunity employer. All qualifications will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, ancestry, national origin, age, disability, handicap, genetics or veteran status. Please answer all the questions as completely as possible. If you feel any questions may violate your rights, please do not answer. Print your answers clearly.

"*" indicates required fields

Step 1 of 5

20%

Section 1 – General Information

Name*

First Last

Address (Permanent)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Division Applying For*

Boston

North Shore

Position applying for*

EMT-Basic

EMT-Advanced

EMT-Paramedic

First Responder – Ambulance Driver (Boston Division Only)

Chair-Car Driver

Dispatcher (Gloucester Only)

Call Taker (Gloucester Only)

Medical Biller (Gloucester Only)

Fleet Mechanic (Gloucester Only)

Type of schedule applying for*

Full Time

Part Time

Per Diem

Seasonal

Are there any shifts you cannot work?

Days

Evenings

Overnights

Weekends

Holidays

More than 40 hr/wk

Rot./Shift

Explain

Referral Source

Walk-in

Relative

Other

Name of Source

Have you ever applied for employment with this company or any other ambulance service?*

Yes

If yes, who and specify date

Have you previously been hired for a position with Beauport Ambulance Service, Inc.?*

Yes

If yes, please indicate DATE and POSITION HELD

Do you have any relatives employed by Beauport Ambulance Service, Inc.*

Yes

Are you legally eligible for employment in the United States?*

Yes

Note: If you are hired, you will be required to submit proof of legal right to work in the United States.

Have you ever served in the U.S. Armed Forces?*

Yes

If you are under 18 years old, do you have working papers?

Yes

Section 2 – Education and Specialized

High School Name*

High School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dates Attended*

Graduated*

Yes

College Name

College Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Degree Type

Major

Dates Attended

Graduated

Yes

Trade or Professional School Name

Trade or Professional School Name Address

Street Address Address Line 2 City State ZIP Code

Dates attended

Graduated

Yes

Degree Type

Major Course

Other

Section 3 – Chair Car and EMS Applicants

All applicants for employment that are scheduled for an interview must provide a current driving record obtained from the Registry of Motor Vehicles, copy of Drivers license, NIMS 100, 200, 700, OEMS cards and HCP-CPR card.

Driver's Licence Number

State of Insurance

Exp. Date

Have you had any moving violations in the last three (3) years?

Yes

If yes, please explain

EMT-B #

Exp. Date

CPR Exp. Date

EMT-A #

Exp. Date

Other

Paramedic #

Exp. Date

EMD Certified

Yes

If yes, membership ID #

Exp. Date

ACLS #

Exp. Date

PALS #

Exp. Date

Please state below your total years of EMS experience, listing your initial certificate date for each level of certification

EMT-B

EMT-I

Paramedic

Section 4 – References

List below three persons NOT related to you and NOT personal friends whom you have known at least one year and who can give a thorough assessment of your job performance and skills.

Person #1 Name

First Last

Phone

Position

Year(s) Acquainted

Person #2 Name

First Last

Phone

Position

Year(s) Acquainted

Person #3 Name

First Last

Phone

Position

Year(s) Acquainted

Section 5 – Computer Software/Radio Skills

Please check all that apply.

Zoll Tablet E-PCR

Zoll Rescuenet DISPATCH

Zoll NAVIGATOR

Panasonic Toughbook

Mobile Radios

GPS Software

Nextel/Sprint

If other, please explain

Section 6

Please check all that apply.

Are you familiar with the following areas?

Gloucester

Rockport

Essex

Manchester

Beverly

Danvers

Peabody

Ipswich

Boxford

Hamilton

Wenham

Salem

Lynn

Boston

Section 7 – Employment History

List below the names of your last three employers (you may list volunteer positions as well as paid positions). List present employer or most recent employer first. You may use the reverse side of this application to provide further information if you wish.

Employer #1 Name

Employer #1 Address

Street Address Address Line 2 City State ZIP Code

Dates of Employment

MM slash DD slash YYYY

From

MM slash DD slash YYYY

Job Title

Starting Salary

Ending Salary

Supervisor Name

Supervisor Phone or Email

Reason for leaving

May we contact for reference?

Yes

Employer #2 Name

Employer #2 Address

Street Address Address Line 2 City State ZIP Code

Dates of Employment

MM slash DD slash YYYY

From

MM slash DD slash YYYY

Job Title

Starting Salary

Ending Salary

Supervisor Name

Supervisor Phone or Email

Reason for leaving

May we contact for reference?

Yes

Employer #3 Name

Employer #3 Address

Street Address Address Line 2 City State ZIP Code

Dates of Employment

MM slash DD slash YYYY

From

MM slash DD slash YYYY

Job Title

Starting Salary

Ending Salary

Supervisor Name

Supervisor Phone or Email

Reason for leaving

May we contact for reference?

Yes

Please state why you feel you would be a good fit at Beauport Ambulance Service, Inc.

Section 8

Please READ CAREFULLY before signing. Note: Beauport Ambulance Service, Inc. is committed to providing a ‘Drug Free’ working environment and all employees are subject to random drug screening. Beauport Ambulance Service, Inc. is an Equal Opportunity Employer. I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I hereby authorize, without reservation, any law enforcement agency, administrator, state agency, institution, information service bureau, employer or insurance company contacted by Beauport Ambulance or its agent to furnish information regarding the above. I understand that the use, purchase, transfer, possession or sale or being under the influence of illegal drugs or controlled substances while on Beauport Ambulances premises, the premises of any Beauport Ambulance worksite, or while engaged in Beauport Ambulance business is strictly prohibited and is grounds for immediate discharge. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment, as required by Beauport Ambulance. I understand that the federal regulations require that my employment be conditioned upon presentation of documents at the time of hire which verify my identity and eligibility to work in the U.S. ( i.e. Passport, certificate of U.S. Citizenship or naturalization, alien registration card, drivers license, U.S. military card, social security card, birth certificate, or other U.S. employment authorization.) I further acknowledge that a fax or photographic copy shall be valid as the original. This release includes all state and federal agencies. Unless otherwise noted, I authorize this Company or its agent to investigate and/or verify all information in this application, including contacting all persons, schools, current employer (if applicable), previous employers and other individuals and entities named herein (and those named on accompanying resume, if any). I hereby authorize my former employers and other third parties named on this application to release information pertaining to my work record, habits and performances. In doing so, I hereby release them and this Company and its agents from all liability which may flow from the release of such information. Should my employment terminate, it is understood that Beauport Ambulance may supply my complete record in response to any bona fide request, and I hereby release Beauport Ambulance and any of its staff from any liability and responsibility in connection therewith. I agree, in the event Beauport Ambulance should employee me, either party for any reason or no reason may terminate my employment at any time. I further agree that this agreement regarding my status as an employee “at will” cannot be changed except in the form of a written agreement signed by the Chief Executive Officer, Chief Financial Officer or Human Resources. I agree that if I become employed with Beauport Ambulance and thereafter, I shall not, without the prior consent of Beauport Ambulance, issue any press release or make any public announcement with respect to my employment with Beauport Ambulance or its clients. If I am contacted by the press regarding Beauport Ambulance or client-related matter, I understand that I am to refer the inquiry to the Director. Following the date hereof and regardless of any dispute that may arise in the future, I shall not, disparage, criticize or make statements which are negative, detrimental or injurious to Beauport Ambulance or its clients, officers or employees. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Name

First Last

Date

Month

Day

Year

Section 9

Have you ever been convicted of any Offenses/Felonies?*

Yes

If yes, explain

Are all of your professional Licenses/Certificates in good standing?*

Yes

Section 1 – General Information

Section 2 – Education and Specialized

Section 3 – Chair Car and EMS Applicants

Section 4 – References

Section 5 – Computer Software/Radio Skills

Section 6

Section 7 – Employment History

Section 8

Section 9

Beauport Ambulance Service, Inc.

Contact Us