edical ransport mployment pplication acket : ll pplicants : anagement hank you for expressing an interest in edical ransport. edical ransport provides non emergency medical transportation for patients of several nursing facilities and private residents throughout the Burlington and amden ounty areas. ur services include both wheelchair and stretcher transportation for many reasons, such as but, not limited to: mergency oom visits, Doctor's ffice visits, physical therapy, dialysis treatments, etc. General equirements for employment: 1 ll applicants must be at least eighteen (18) years of age prior to starting work for. 2 ll applicants must have a valid driver's license. mergency edical echnician () requirements: 1 ll applicants must have a valid for the rofessional escuer certification. 2 ll applicants must be certified as a J, ational egistry, or be certified as an in a tate in which J honors. ull ime mployment: n employee who is regularly scheduled to work at least 32 hours/week is a regular full time employee. ull ime employees are responsible for at least one n all per week. art ime mployment: n employee who is regularly scheduled to work less than 32 hours/week but at least 24 hours/week is a part time employee. art ime employees are not eligible for benefits except as required by law or as provided by a specific policy, or applicable plan document. er Diem mployment: n employee who is hired to perform services to on a basis other than a regular schedule. er Diem employees are not eligible for benefits except as required by law, or as provided by a specific policy, or applicable plan document. er Diem employees must maintain an availability schedule with the dispatch center. er Diem employees are required to be available to work a minimum of sixteen (16) hours during each calendar month. nstructions for completing this application: 1 omplete all information that is requested. f a questions does not apply to you write "/". 2 Be sure to sign the "uthorization to elease nformation" and the mployment pplication. 3 nclude a copy of your driver's license and any certification you hold, such as a or card. *We can make copies at our office when you come to drop off your application. ll certifications must be valid and a copy must be provided to edical ransport. "s eeded" rev. 04/07 age 1 of 6
edical ransport UHZ D B s part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. he investigative consumer report may consist of contacting all listed prior employers to verify your employment history. t may also include, but not be limited to, credit information reports, criminal history reports and driving history records. Under the provisions of the air redit eporting ct (15 U at 1681 1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. ou have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. ou are also entitled to a copy of your ights Under the air redit eporting ct. Under the provisions of the air redit eporting ct, 15 U, ection 1681 et seq., the mericans with Disabilities ct and all applicable federal, state, and local laws, hereby authorize and permit B.. V,. D/B/ D to obtain a consumer report and/or an investigative consumer report which may include the following: 1 y employment records; 2 ecords concerning any driving, criminal history, credit history, civil record, workers compensation (post offer only) and drug testing; 3 n accordance with the Department of ransportation otor arrier afety egulations, ection 382.413, information concerning alcohol and controlled substances for the past 2 years; 4 Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records. understand that an investigative consumer report may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom am acquainted or who may have knowledge concerning any such items of information. agree that a copy of this authorization has the same effect as an original. hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as B.. V,. D/B/ D from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. understand and acknowledge that under provision of the air redit eporting ct may request a copy of any consumer report from the consumer reporting agency that compiled the report, after have provided proper identification. hereby authorize B.. V,. D/B/ D to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my employment application. his authorization shall remain in effect over the course of my employment. eports may be ordered periodically during the course of my employment. ull ame: (rinted ame) ignature Date Date of Birth: : rev. 04/07 age 2 of 6
edical ransport mployment pplication oday's Date: D U ast ame: irst ame: iddle nitial: ity: tate: Zip ode: Home elephone umber: obile elephone umber: partment/unit umber: Date of Birth: (/DD/) ge: ocial ecurity umber: Driver's icense umber: tate: Have you ever been arrested for a crime, regardless of a conviction, which has not been annulled, expunged or sealed by the court? Have you ever been convicted of any crime, excluding minor traffic offenses, which have not been annulled, expunged or sealed by the court? es o xplain: ertified? f yes, what is the xpiration Date. ertified? f es, who is the issuing authority and what is the xpiration Date..J. ther: es o X. es o X. Desired osition: mployment tatus Desired: Days vailable each Week: hifts vailable for: (art ime nly) Wheelchair Van Driver (V) ull ime ( > 32hrs. /Week) on hu un Days (8:00a to 4:00p) mergency edical echnician () art ime ( > 24hrs. but < 32hrs. / Wk) ue ri vening (4:00p to 8:00p) ther: er Diem (at least 16hrs. / onth) Wed at ny Weekends (ll imes) Date you are available to start work: Desired alary: (per Hour) Were you referred to by any current employee? f yes, by whom? Have you ever worked for in the past? f yes, give dates and reason for leaving. es o tart: nd: High chool ollege Business rade/ech Business rade/ech / / ame of chool ocation (ity,tate,zip) ame of chool ocation (ity,tate,zip) ame of chool ocation (ity,tate,zip) ame of chool ocation (ity,tate,zip) $ eason for eaving: ourse of tudy Dates rom/o: Did you Graduate? ourse of tudy Dates rom/o: Did you Graduate? ourse of tudy Dates rom/o: Did you Graduate? ourse of tudy Dates rom/o: Did you Graduate? rev. 04/07 age 3 of 6
ompany ame: ist both full time and part time employment history, including military service. tart with your most recent employer. ame of upervisor: (must be filled in) 1 ity: tate: Zip ode: elephone umber: Job itle: Dates of mployment: tarting alary: nding alary: tart: nd: $ $ Job Description and esponsibilities: (note any special duties or responsibilities) eason for leaving: (give a full description as to why you left or are leaving this employer) Voluntary Quit erminated H 2 ompany ame: ame of upervisor: (must be filled in) ity: tate: Zip ode: elephone umber: Job itle: Dates of mployment: tarting alary: nding alary: tart: nd: $ $ Job Description and esponsibilities: (note any special duties or responsibilities) eason for leaving: (give a full description as to why you left or are leaving this employer) Voluntary Quit erminated ompany ame: ame of upervisor: (must be filled in) 3 ity: tate: Zip ode: elephone umber: Job itle: Dates of mployment: tarting alary: nding alary: tart: nd: $ $ Job Description and esponsibilities: (note any special duties or responsibilities) eason for leaving: (give a full description as to why you left or are leaving this employer) Voluntary Quit erminated rev. 04/07 age 4 of 6
ist three references not related to you, who have known you for at least two years. Do not repeat names of supervisors listed under employment history. 1 ast ame: irst ame: iddle nitial: ity: tate: Zip ode: Home elephone umber: obile elephone umber: partment/unit umber: 2 3 ast ame: irst ame: iddle nitial: partment/unit umber: ity: tate: Zip ode: Home elephone umber: obile elephone umber: ast ame: irst ame: iddle nitial: partment/unit umber: ity: tate: Zip ode: Home elephone umber: obile elephone umber: certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. ull ame: (rinted ame) ignature Date * K U U D D G H "UHZ D B " * rev. 04/07 age 5 of 6
* D W H G. pplicant valuation and Determination B K G U D D mployer 1 ontact ame: mployer 2 ontact ame: mployer 3 ontact ame: Discussion esults and otes: ass ail otes: Discussion esults and otes: ass ail otes: Discussion esults and otes: ass ail otes: Driving ecord esults: lear ailure to yield umber of oints on icense: Zero Driving ecord: V < 2yrs. peeding (1 14 H over) ailure to observe 1 4 7 10 V > 2yrs. peeding (15 29 H over) areless Driving 2 5 8 11 ass ultiple V's #: peeding (30 H or over) eckless Driving 3 6 9 12 ail riminal ecord esults: lear rrested onvicted cquitted riminal ecord: ass harges: ail V W Does the applicant have any experience in the medical transportation field? f yes, where at?, How long has the applicant been there?, Duties? X How long has the applicant been an mergency edical echnician or obility ssistance Vehicle echnician? otes: U nterviewed by: res. V Dir. ps. mployee Job itle: Days and hifts ermanent chedule: V on 8a 4p 4p 8p ther: ue 8a 4p 4p 8p ther: ffered osition? f yes, starting salary/wages: ther: Wed 8a 4p 4p 8p ther: es o $ mployee tatus: hu 8a 4p 4p 8p ther: ull ime ri 8a 4p 4p 8p ther: eporting to work on: art ime at 8a 4p 4p 8p ther: er Diem un 8a 4p 4p 8p ther: rev. 04/07 age 6 of 6