APPLICATION FOR EMPLOYMENT Cooperstown Medical Transport

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1 APPLICATION FOR EMPLOYMENT Cooperstown Medical Transport PERSONAL INFORMATION (PLEASE PRINT) (FIRST, MIDDLE, LAST) SSN PHONE CELL PHONE Best Time To Be Reached: REFERRAL SOURCE WALK IN ADVERTISEMENT RELATIVE EMPLOYMENT AGENCY EMPLOYEE OTHER If referred by a current employee, please state name: If referred by an agency, please state agency name: POSITION DESIRED EMT-B EMT-I EMT-CC PARAMEDIC MAINTENANCE MECHANIC DISPATCHER OTHER Our positions require working weekends, evenings and/or holidays, is this acceptable? Date Available: Minimum Pay Acceptable $ per ELIGIBILITY/HISTORY Are you eligible to work in the United States? Are you at least 18 or older? Have you ever been convicted of a crime? If yes, please explain: Have you ever been excluded, debarred, suspended, or otherwise determined to be ineligible to participate as a provider or employee or agent of a provider of health care services? Have you ever been convicted of, plead no contest to or been the beneficiary of a plea agreement involving a criminal offense charged against you related to health care? Have you ever been employed by Cooperstown Medical Transport? Please list any relatives in our employ and relationship: Do you have a contact or agreement with another company that may limit your availability to perform work for Cooperstown Medical Transport (e.g., a non-compete agreement)? Have you ever been known by any other names? If so, please list: QUALIFICATIONS TYPE OF TRAINING EXPIRATION LEVEL INSTRUCTING AGENCY CERTIFICATION # EMT FIREFIGHTER CPR OTHER Cooperstown Medical Transport1

2 EMPLOYMENT RECORD (Please list 3 employers, most current first. We will be contacting supervisors for references.) COMPANY SUPERVISOR S PHONE COMPANY SUPERVISOR S PHONE No COMPANY SUPERVISOR S PHONE EDUCATION HIGH SCHOOL GRADUATED EDUCATION COLLEGE OR UNIVERSITY GRADUATED - DEGREE/MAJOR EDUCATION GRADUATE SCHOOL GRADUATED DEGREE/MAJOR OTHER JOB RELATED COURSES SPECIAL SKILLS, TRADE, SPECIALIZED TRAINING, APPRENTICESHIP, EXTRACURRICULAR ACTIVITIES: Cooperstown Medical Transport2

3 PERSONAL REFERENCES (Not to include Relatives or Employments) Cooperstown Medical Transport3

4 Acknowledgement of Receipt Representatives of Cooperstown Medical Transport may not enter into an employment agreement for a specified period of time without express written consent of the Company s Chief Executive Officer or his/her designee. As part of the employment application process at Cooperstown Medical Transport and for subsequent employment purposes (if you are hired), a consumer report may be obtained. This type of report is generally called a credit or background check and may include information on your credit standing and capacity, character, general reputation, personal characteristics, driving record or mode of living. In accordance with the Fair Credit Reporting Act, by signing below you authorize any reference, school, former employer or other person to disclose to Cooperstown Medical Transport upon request any information they may have about me and I release them from all liability for disclosing such information to Cooperstown Medical Transport. Any reports provided to Cooperstown Medical Transport will not contain medical information. The information provided in this Application for Employment is true and complete. Cooperstown Medical Transport may disqualify me from consideration for employment or terminate my employment for any false or misleading statements or omissions in the Application, whenever they may be discovered. I understand that this application does not, by itself, create a contract of employment with Cooperstown Medical Transport. PRINT APPLICANT APPLICANT SIGNATURE Cooperstown Medical Transport and federal state laws prohibit discrimination on the basis of race, color, religion, national origin, sex, age or disability. Application May Be Submitted In Person, or Mailed To: CMT 599 Delaware County Hwy. 11 Oneonta, NY Cooperstown Medical Transport4

5 Cooperstown Medical Transport BACKGROUND INVESTIGATIVE AUTHORIZIATION In connection with my employment or application for employment or promotion with Cooperstown Medical Transport, Inc., I understand that background inquires may be requested by you, or on your behalf that will seek information as to my character, work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Further, I understand and agree that you may request information from various federal, state and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, criminal record, credit history, civil matters, previous employment, education background, professional licensing, as well as other experiences. I acknowledge that a telephone facsimile or copy of this release shall be as valid as the original. This authorization is valid for any consumer report request at any time during the tenure of my employment. This release is valid for all federal, state, county and local agencies and school authorities. I understand that I have the right to make a written request within a reasonable period of time for complete and accurate disclosure of information concerning the nature and scope of this investigation. Print Name Social Security Number Date of Birth Driver s License Number State Current Address City State Zip List Previous addresses and names (Maiden and/or aliases) used during the past 7 years Name Address City, State, Zip County Applicant Signature: Date: Cooperstown Medical Transport5

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