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Highly skilled and certified EMS Professionals

Highly skilled and certified Ambulance Services

Online Application

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Applications for employment are considered for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
All applications submissions are secure and served through https:// server.

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Basic Details

Position Applying For*

EMT

Paramedic

Dispatcher

Sales

Call Taker

Office Staff

Ambulance Driver

Sales

Other

If other, please specify*

Personal Details

Name*

First Last

Submission Date

Separate tags with commas

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Email*

Social Security #

Date of Birth*

Month

Day

Year

Age*

EMS Cert. Level

NYS EMS ID #

Driver License #

State Licensed in

Expiry Date

MM slash DD slash YYYY

Upload Copy of License

Accepted file types: jpg, pdf, png, gif, doc, docx, Max. file size: 128 MB.

License Class

Expiry Date

MM slash DD slash YYYY

Board of Education Certification Level

Driver

EMT

Paramedic

Board of Education Certified

Yes

Please Check Off Current Availability

Type

Full Time (32-40 hours per week)

Part Time (8-24 hours per week)

Per Diem (As Available)

Shift

Days

Nights

Overnights

Days

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

EMPLOYMENT EXPERIENCE

Start with your present or most recent employer. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected statuses.

Employment

Employer

Title

Employed From Date

MM slash DD slash YYYY

Employed To Date

MM slash DD slash YYYY

Address

Full Address

Supervisor

First Last

Telephone

Brief description of duties

Reason for leaving

May we contact your Employer?

Yes

EMPLOYMENT QUESTIONNAIRE

Have you ever filed an application with Assist Ambulance before?*

Yes

Please give the date*

MM slash DD slash YYYY

Have you ever been employed by Assist Ambulance before?*

Yes

From

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

If you are under 18 years of age can you provide proof of your eligibility to work?*

Yes

Are you a United States Citizen?*

Yes

If no, can you provide proper documentation proving your eligibility to work?*

Yes

Are you currently on "lay-off" status and subject to recall?*

Yes

May we call your present employer?*

Yes

If no, please explain why*

EDUCATION

High School

High School Name

Address

Years Completed

Graduate

Yes

Undergraduate School

Undergraduate School Name

Address

Major

Years Completed

Graduate

Yes

Graduate Professional

Graduate School Name

Address

Major

Years Completed

Graduate

Yes

Other (Specify)

Other School Name

Address

Major

Years Completed

Graduate

Yes

SPECIAL QUALIFICATIONS

Below please list any special qualifications that may or may not make you more qualified for the position you are applying for

TELL US ABOUT YOURSELF

Below please tell us what would make you an asset to have at Assist Ambulance

How did you learn about our company*

Indeed

Employee

School

Seen on the ambulances

Other

School Name

Name of Person at School

Other, please explain

Employee Name

Advertisement Name or Type

I understand that all information filled out on this application must be true and information that is fraudulent or purposely misleading can be grounds for disqualification from employment or termination if found out about after being employed.

Print Name*

Signature*

Hidden

For Office Use Only

Supervisor

Hidden

Status

Hire

Call Back

No Hire

Hidden

Employment Type

Full Time

Part Time

Per Diem

Hidden

Name

First Last

Hidden

Signature

CONSENT FORM-DISCLOSURE OF INFORMATION

Name*

First Name Last Name

Date of Birth

Month

Day

Year

Social Security #:

Drivers License #

State

EMT/P #

Address

Street Address City State ZIP Code

I give consent for my driver’s license to be verified to be valid as well as permission to check my entire driver’s abstract including driving history, violations, suspensions, or infractions, noted by the Department of Motor Vehicles. This driving history will be taken into consideration when considering employment opportunities. Upon employment, your license will be registered under the NYS DMV LENS program, which would notify a designated manager at Assist Ambulance whenever you receive a moving violation, your license is suspended, or revoked, or any other derogatory event on your license.

In accordance with all applicable statutes and laws, I hereby give my written consent to Assist Ambulance to contact any and all of my employer(s) or former employer(s) for any and all records relating to me while I was employed by that company. This includes all written documents that are part of my employee file and anything that is known and is not in the file. This can be transferred by mail, electronically, or by oral report. I acknowledge by this authorization that I such company from any obligation and liability in the disclosure of the contents of such files and the professional observations or opinions contained therein.

Name*

First Name Last Name

Signature*

Date

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

We are an equal opportunity Employer

Highly skilled and certified EMS Professionals

Highly skilled and certified Ambulance Services

Online Application

Basic Details

Personal Details

Please Check Off Current Availability

EMPLOYMENT EXPERIENCE

Employment

EMPLOYMENT QUESTIONNAIRE

EDUCATION

SPECIAL QUALIFICATIONS

TELL US ABOUT YOURSELF

For Office Use Only

We are an equal opportunity Employer

Locations

Executive Offices

Dispatch/Transportation

Marketing/Sales