Employment Application

Transcription

1 Employment Application Ryan Brothers Ambulance, Inc. 922 S. Park Street Madison, WI Phone: Fax:

2 EMPLOYMENT APPLICATION APPLICANT INSTRUCTIONS Individuals who need assistance with any portion of this application process should call and follow the prompts for HR. 1. Complete all pages in the application file. 2. Print and mail to Ryan Brothers Ambulance, ATTN: Patrick Ryan, 922 S Park St, Madison, WI POSITION APPLIED FOR: TODAY S DATE: LAST NAME: FIRST NAME: PHONE: CELL: CURRENT ADDRESS: CITY: STATE: ZIP: PREVIOUS ADDRESS: CITY: STATE: ZIP: PREVIOUS ADDRESS: CITY: STATE: ZIP: POSITION APPLYING FOR Emergency Medical Staff Dispatch Admin Full Time Part Time hours available: What date can you start? Yes No Do you have any geographical restrictions? Yes No Do you have a dependable means of transportation to and from work? (this would include all seven locations see the list at Yes No Do you have any availability restrictions? If yes, please explain: EDUCATION Please indicate any education and training you believe is directly related to the skills needed to perform the job you are applying for. If your school records are under a different name than listed above, please enter that name: INSTITUTION / ORGANIZATION CITY / STATE DEGREE TYPE GRADUATED Yes No Yes Yes Yes No No No REFERENCES Include only individuals familiar with your work ability. Do not include relatives, members of your household or supervisors listed later in the application. NAME ADDRESS PHONE NUMBER YRS KNOWN

3 PREVIOUS EMPLOYERS PLEASE NOTE: Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. MOST RECENT EMPLOYER: SECOND MOST RECENT EMPLOYER: THIRD MOST RECENT EMPLOYER:

4 PREVIOUS EMPLOYERS CONTINUED FOURTH MOST RECENT EMPLOYER: FIFTH MOST RECENT EMPLOYER: SIXTH MOST RECENT EMPLOYER:

5 FOR MEDICAL STAFF APPLICANTS ONLY (Dispatch and Admin Applicants please continue to the next page) LICENSES & CERTIFICATIONS Yes No Are you licensed/certified for the job for which you are applying? Yes No Is your CPR current within the past 12 months? Expiration of certification: Yes No Are you affiliated with any EMS System(s)? Medical license level: License # Exp. Date: System Name(s): Yes No Are you current with continuing education hours? Current amount of CE Hours completed: Yes No Has this license ever been suspended or revoked? If yes, state the reason(s), the date(s) of revocation or suspension, and the date of reinstatement. JOB REQUIREMENTS All Emergency Medical Staff are required to pass our insurance company s screening process in order to drive a company vehicle. The list of criteria used is available upon request. Yes No One requirement for insurability is being at least 18 years of age. Do you meet this requirement? Yes No Do you have a valid Driver s License? License #: Issuing State: Exp. Date: DOB: Yes No Has your Driver s License ever been suspended or revoked? If yes, state the reason(s), the date(s) of revocation or suspension, and the date of reinstatement. Yes No EMS staff need to lift, with a partner, a stretcher loaded with 250 lbs several times a day. Are you able to meet this requirement? Yes No All applicants will be screened through the Wisconsin Department of Transportation. Is there any additional information we should be made aware of? If yes:

6 PERMISSION TO WORK IN THE UNITED STATES Yes No Are you a United States citizen or do you have an entry permit which allows you to lawfully work in the U.S.? CRIMINAL HISTORY PLEASE NOTE: Responses in this area do not constitute an automatic bar to employment and will be considered ONLY as it directly relates to the job you are applying for. Ryan Brothers Ambulance medical positions may perform services with vulnerable populations. Use the Additional Information page for any explanations. Yes No Have you ever been convicted of a crime? DO NOT INCLUDE CONVICTIONS THAT WERE SEALED OR EXPUNGED PURSUANT TO A COURT ORDER. Yes No Are you or have you ever been required to register as a Sex Offender? APPLICANT NOTE I Hereby Certify that the answers given by me to the above questions and statements are true and correct and hereby authorize you to contact references, past or present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to my application for employment. It is understood and agreed that any misrepresentation, false statement, or omissions by me in this Application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to Ryan Brothers Ambulance. This includes furnishing false name or social security number. I have read, understand and agree to the above statement. Please initial here CERTIFICATION AND RELEASE If employed, I agree to abide by all of the work and safety rules of Ryan Brothers Ambulance. I understand that Ryan Brothers Ambulance is committed to maintaining a drug-free workplace. I am aware that Ryan Brothers Ambulance may require a drug test as part of the hiring process. Also, if employed, I realize that Ryan Brothers Ambulance conducts postaccident, reasonable suspicion, drug and/or alcohol testing of its employees. I have read, understand and agree to the above statement. Please initial here Signature Date

7 ADDITIONAL PAGE SECTION ADDITIONAL COMMENTS

8 APPLICANT DISCLOSURE AND CONSENT TO REQUEST CONSUMER REPORT INFORMATION I understand that Ryan Brothers Ambulance may utilize the services of a consumer reporting agency as part of the procedure for processing my application for employment. I also understand that if hired, Ryan Brothers Ambulance may obtain further information through subsequent investigations by a consumer reporting agency so as to update, renew, or extend my employment, or for consideration for reassignment or promotion. I understand that information obtained from a consumer reporting agency s investigation may include information from the previous seven (7) years. This information may include credit background, references, past employment, work habits, education, judgments, liens, criminal background, character, general reputation and driving records. Information regarding bankruptcy filing(s) may include information from the previous ten (10) years. I understand that such information may be obtained by direct or indirect contact by a consumer credit agency with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. I also understand that, pursuant to the Fair Credit Reporting Act, 15 U.S.C. 1681a, et seq., (FCRA), before I am denied an assignment, extension, reassignment or promotion of employment, or other benefit of employment, based in whole or in part, on information obtained in the report, Ryan Brothers Ambulance will provide me with a copy of the report and a copy of A Summary of Your Rights Under the Fair Credit Reporting Act. I understand that if I disagree with the accuracy of any of the information in the report, I must notify Ryan Brothers Ambulance within five (5) days of my receipt of the report. I hereby consent to this investigation and authorize Ryan Brothers Ambulance to procure a report of my background as stated above from a consumer reporting agency. I agree that a facsimile or photocopy of the form is valid just like the original form. This report will be processed by: Ryan Brothers Ambulance, Inc. 922 S. Park Street Madison, WI Phone: Fax: Applicant s name (print): SSN: Signature: Date: