Employment Application

APPLICATION FOR EMPLOYMENT

  

 CITIZENSHIP

STATEMENT OF HEALTH

EMPLOYMENT HISTORY

Give a complete record of all employment and reasons for period of unemployment during the past during the past ten years. Start with most recent employment.

EMPLOYMENT INFORMATION

EMPLOYMENT 2

EMPLOYMENT 3

U. S. MILITARY SERVICE


In accordance with the Mont Alto Ambulance Association Policy Manual all employment candidates for employment dealing with the public are required to submit a criminal history report, a drug/alcohol test, and a current PA. Drivers licenses. The Mont Alto Ambulance Association requires all employment candidates to answer the following questions.

EDUCATION AND EXPERIENCE

Name & Address of highest grade, Degree or Certification

Professional Licenses, Registrations and or Certifications

REFERENCES

Please give 3

AFFIDAVIT
(Read before signing)

I certify that the answers given by me to be foregoing questions and statements are true and correct without omissions of any kind whatsoever. L understand that the Mont Alto Ambulance Association may terminate my employment due to the falsity of statements, answers or omissions made by me in this questionnaire. I authorize the hospitals, companies, schools or persons named above to give information regarding my employment, together with any other information that they may have regarding weather or not it is in my records. I hereby release said hospitals, companies, schools, or persons from all liability for any damage for this information. I also understand that an offer of employment will be conditioned on the results of a medical examination and a substance abuse screening in addition, if accepted for employment, I hereby agree to abide the rules and policies of the Mont Alto Ambulance Association.

REFERENCE RELEASE INFORMATION

In connection with my employment application now on file with the Mont Alto Ambulance Association of Pennsylvania, I hereby authorize that you complete its form regarding my employment with you. I specifically request that you also include any adverse information concerning my work experience with you.

I hereby release and agree to hold you harmless from any and all liabilities of any kind and nature in connection with your furnishing this information to the Mont Alto Ambulance Association.

PRE-EMPLOYMENT INQUIRY RELEASE

In connection with my application for employment with the Mont Alto Ambulance Association, I understand that investigative background inquiries are to be made on myself including criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employer's. Further, I understand that the Mont Alto Ambulance Association will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil and other experiences as well as claims involving in the files of insurance companies.

I hereby authorize, without reservation, any party or agency contacted by the Mont Alto Ambulance Association to furnish the above mentioned information.