General Inquiries

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500 Neponset Avenue
Boston, MA, 02122
United States

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Application Page

Position(s) applied for: *
Requested employment schedule: *
Personal information
Name *
Name
Address *
Address
Phone *
Phone
EMS credential information
Proof of credential information is required as part of the application process since they are a mandatory requirement for EMS employment pursuant to M.G.L. 111C, 105 CMR 170.000.
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Other education, skills and/or qualifications for informational purposes: *
Check ALL that apply.
If you answered that you completed collage or technical training please list your degree(s) or certificate(s) here.
Licenses, Certificates, Job related Training or Other Training. Please enter any and all here.
References
(Please do not include relatives and/or current employers)
Reference 1 *
Reference 1
Telephone *
Telephone
Permission to contact?
Reference 2 *
Reference 2
Telephone *
Telephone
Permission to contact? *
Reference 3 *
Reference 3
Telephone *
Telephone
Permission to contact? *
MOST RECENT EMPLOYMENT
Provide the following information for your current and/or past two employers.
$
EMPLOYER ADDRESS *
EMPLOYER ADDRESS
SUPERVISOR'S PHONE *
SUPERVISOR'S PHONE
START DATE *
START DATE
END DATE *
END DATE
REASON(S) FOR LEAVING *
PREVIOUS OR OTHER RECENT EMPLOYMENT
$
EMPLOYER ADDRESS
EMPLOYER ADDRESS
SUPERVISOR'S PHONE
SUPERVISOR'S PHONE
START DATE
START DATE
END DATE
END DATE
REASON(S) FOR LEAVING
Terms and Conditions
I hereby authorize EasCare to contact, obtain and verify the accuracy of the information contained in this employment application from all previous employers, educational institutions and references. I also hereby release from liability EasCare and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for the cancellation of this application or immediate termination of my employment when it has been or is discovered. If I become an EasCare employee, I acknowledge that there is no specific length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, I acknowledge and understand that either I or EasCare can terminate the relationship at will, with or without cause at any time so long there is no violation of applicable federal and/or state law(s). I understand that it is the policy of EasCare not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the American Disabilities Act (ADA). I also understand that if I become employed, it is my responsibility to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing and that I seek employment under these conditions.
Signature
I represent that I have fully understood the following questions, that my answers are truthful and accurate, and that the omission of any material fact, commission of any false statement, and/or any attempt to misrepresent the truth will result in immediate termination. I further understand that knowingly making an omission of a material fact or a false statement is in violation of 105 CMR 170940: Grounds for Suspension. Revocation of Certification, or Refusal to Renew Certification and said issue will be forwarded to the Department of Public Health (Department), Office of Emergency Medical Service (OEMS) for investigation.
Date *
Date
ADDITIONAL INFO
Please answer the following questions honestly and accurately. The omission of any material fact, the commission of any false statement, and/or any attempt to misrepresent the truth will result in immediate termination. Furthermore, to knowingly make an omission of a material fact or false statement is in violation of 105 CMR 170940: Grounds for suspension, Revocation of Certification, or Refusal to renew Certification and will be forwarded to the Department of Public Health (Department), office of Emergency Medical Services (OEMS) for investigation. Any answer in the affirmative will be reviewed and assessed. Based on said statement. A decision will be made relative to whether or not you are eligible for hire. An answer in the affirmative will not automatically exclude you from an employment opportunity. If you require assistance in answering any of the following questions, please tell the manager on duty. It is essential that you understand what is being asked of you.
1a. Have you ever been the subject of an OEMS investigation? *
2a. Has the department ever suspended, revoked, refused to renew your EMT certification or taken any other type of disciplinary action against you/or your EMT certification including, but not limited to , letter of reprimand, letter of clinical deficiency, advisory letter? *
3a. Has any Physician or Hospital ever taken any action against your authorization to practice including, but not limited to, restricting it in any way, suspending it, or revoking it? *
4a. Has any employer ever restricted you from functioning at the full level of you EMT certification (i.e. prohibiting an Emt-Paramedic from working at the EMT-Paramedic level and restricting said EMT-Paramedic to working at a lesser lever such as EMT-Intermediate or Basic or prohibiting am EMT-Basic from working as an EMT-Basic and restricting said EMT-Basic to working only as a Chair van driver)? *
Confirmation
I represent that I have fully understood the following questions, that my answers are truthful and accurate, and that the omission of any material fact, commission of any false statement, and/or any attempt to misrepresent the truth will result in immediate termination. I further understand that knowingly making an omission of a material fact or a false statement is in violation of 105 CMR 170940: Grounds for Suspension. Revocation of Certification, or Refusal to Renew Certification and said issue will be forwarded to the Department of Public Health (Department), Office of Emergency Medical Service (OEMS) for investigation.
Name *
Name
Date *
Date