EasCare Lcc

Phone: 617-822-4400

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Worcester

APPLICATION FOR EMPLOYMENT

EasCare is an equal opportunity employer and does not allow any unlawfully discriminatory practices associated with employment. Therefore, none of the questions on this employment application will be used for the purpose of limiting or excluding any applicant from consideration for employment as prohibited by local, state, or federal law. Equal access to employment, employee services, and programs is available to all persons. Any applicant(s) who require reasonable accommodations pertaining to the application and/or interview process should notify a representative of EasCare upon submitting the application for employment.

PART A

PART B

Position(s) applied for: check ( √ ) box
	Chair Car Operator
	Emergency Medical Technician
	EMT-Intermediate
	Paramedic
	Office/Billing

Requested employment schedule: check ( √ ) box
	Full Time
	Part Time / Schedule Hours per week
	Per Diem (on an as needed basis only)
	Hours per week # desired hours

First Name:
Middle Initial:
Last Name:
Social Security:	- -
Street Address:
City/Town:
State:
Zip:
Telephone:	( ) -
Pager:	( ) -
Cellular Telephone:	( ) -

Have you been convicted of a crime in the past five (5) years? Yes No

If yes, you will need to provide a brief explanation during the interview process. Please note that a conviction will not automatically exclude you from an employment opportunity.

EMS CREDENTIAL INFORMATION

Level of EMT Certification: EMT-Basic EMT-Intermediate EMT-Paramedic

Massachusetts Certification Number:	Expiration Date:	/ /
Basic Cardiopulmonary Resuscitation (BCLS/CPR)	Expiration Date:	/ /
Advanced Cardiac Life Support (ACLS) [ PARAMEDICS ONLY]	Expiration Date:	/ /
Drivers License #	Expiration Date:	/ /

Proof of the above 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.

Other education, skills and/or qualifications for informational purposes: [ check ( √ ) ALL that apply]

Completed High School or GED

Presently in college

Completed college: Associates Degree Bachelors Degree Masters Degree

Completed Technical Training:

Pediatric Advanced Life Support (PALS)

Neonatal Advanced Life Support (NALS)

BCLS Cardiopulmonary Resuscitation (CPR)-Instructor

Advanced Cardiac Life Support (ACLS)-Instructor

Currently in or will be in an EMT-Intermediate Program

Currently in or will be in an EMT-Paramedic Program

Firefighter training and/or experience

Law enforcement training and/or experience

Licenses

Certificates

Job related training

Other training, etc.

References: (Please do not include relatives and/or current employers)

1. Name:	Check-If we have permission to contact
Years known: 1 2 3 4 5 6 7 8 9 10+
Telephone ( ) -

2. Name:	Check-If we have permission to contact
Years known: 1 2 3 4 5 6 7 8 9 10+
Telephone ( ) -

3. Name:	Check-If we have permission to contact
Years known: 1 2 3 4 5 6 7 8 9 10+
Telephone ( ) -

HOW DID YOU HEAR ABOUT EASCARE AMBULANCE SERVICE?

Employment History: Provide the following information for your current and/or past two employers

MOST RECENT EMPLOYMENT

EMPLOYER/COMPANY NAME:		HOURLY RATE $ .
STREET ADDRESS:
CITY/TOWN:	STATE:	ZIP:
IMMEDIATE SUPERVISOR NAME:	TITLE:	TELEPHONE:
JOB POSITION TITLE:	START DATE:	END DATE:
REASON(S) FOR LEAVING: NOT APPLICABLE STILL EMPLOYED DESIRE FOR CAREER CHANGE DOWN SIZING RESIGNATION TERMINATION OTHER

PREVIOUS OR OTHER RECENT EMPLOYMENT

EMPLOYER/COMPANY NAME:		HOURLY RATE $ .
STREET ADDRESS:
CITY/TOWN:	STATE:	ZIP:
IMMEDIATE SUPERVISOR NAME:	TITLE:	TELEPHONE:
JOB POSITION TITLE:	START DATE:	END DATE:
REASON(S) FOR LEAVING: NOT APPLICABLE STILL EMPLOYED DESIRE FOR CAREER CHANGE DOWN SIZING RESIGNATION TERMINATION OTHER

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.

Applicant Signature Date / /