NDP Employment Application Revised 2020

P.O. Box 672 Rhinebeck, NY 12572 (845) 876-0338 (800) 580-2909 Fax (845) 876-7071 www.ndpems.com
Thank you for your interest in employment with NDP Emergency Medical Services!

To ensure that full consideration may be given to your application, please:
Print legibly and fill in all blanks. If something does not apply please write N/A. Provide the name, address, title and contact information for current and former employers, including a phone number. Complete the enclosed General Consent for Release of Personal Information form in the presence of a Notary Public (page 10 A Notary Public is available on our premises during most weekdays, from 8 AM to 4 PM if you do not have access to one, at no charge to you. Please call ahead to ensure that the Notary is present. Complete the Consent to Drug and/or Alcohol Testing page including the witness signature. (EMS applicants) Please read and understand the official New York State Job Description for Emergency Medical Technician. EMS applicants must be able to fulfill 100% of the job requirements listed on this Job Description. Sign and date on all sections of the application as required. Enclose a legible copy of the front and back of your Driver License, New York State certification card, Healthcare Provider CPR card and all other necessary credentials. DO NOT enclose a copy of your Social Security Card with the application.
Incomplete applications will not be considered.

Prospective candidates for EMS employment will be asked to successfully complete a written baseline competency exam and a practical skills baseline competency.

Completed applications may be mailed, scanned and emailed, faxed or dropped off in person. Our contact information is listed at the top of this letter. If you have any questions, or would like to follow up on your application, please feel free to contact HR at NDP Station 1 in Rhinebeck at (845) 876-0448, extension 125. Thanks for applying and best wishes in your search for employment.
P.O. Box 672 Rhinebeck, NY 12572 (845) 876-0338 (800) 580-2909 Fax (845) 876-7071 www.ndpems.com
EMPLOYMENT APPLICATION
PERSONAL INFORMATION
First Name
(Middle)
(Last)
(Mailing Address)
(Physical Address, If Different from Mailing Address)
City:
State:
Zip Code:
EMPLOYMENT DESIRED

Paramedic EMT Dispatcher Other
What Employment Status Are You Seeking (Select All That Apply)

Full-Time Part-Time Per-Diem
Date Available to Start:

Month Day Year
Date
Are You Currently Employed?

Yes No
If yes, may we inquire of your present employer?

Yes No
Your current work schedule:
Have You Ever Filed An Application With Us Before?

Yes No
If Yes, the approximate date it was filed:

Month Day Year
Date
EMPLOYMENT HISTORY
List your last three employers below, beginning with the most recent:
Date of Employment

Beginning and End Date
Most Recent
Name of Employer, Address, Telephone Number, Supervisor’s Name & Position Held
Reason for Leaving
Date of Employment

Beginning and End Date
2nd Most Recent
Name of Employer, Address, Telephone Number, Supervisor’s Name & Position Held
Reason for Leaving
Date of Employment

Beginning and End Date
3rd Most Recent
Name of Employer, Address, Telephone Number, Supervisor’s Name & Position Held
Reason for Leaving
PROFESSIONAL REFERENCES
(Name) #1
(Address)
(Phone Number)
(Name) #2
(Address)
(Phone Number)
(Name) #3
(Address)
(Phone Number)
SPECIAL SKILLS AND/OR TRAINING
Summarize any special job related skills and/or training which may be an asset to the position for which you are applying:
DRIVING EXPERIENCE
Do you possess a valid Driver License?
Yes No
State of Issue
If Yes, date License was first issued:

Month Day Year
Date
Current Expiration:
Driver ID Number:
List below, any traffic violations, accidents, and/or revocations you may have incurred during the last 40 months:
Date:

Month Day Year
Date
Violation
Date:

Month Day Year
Date
Violation
Date:

Month Day Year
Date
Violation
FORMAL EDUCATION
Educational Institution

High School
Name and Address
Dates
Years Attended
Certificate/Degree
Institution

Secondary Educaion
Name and Address
Years Attended
Certificate of Degree Earned
Name and Address of Additional Secondary School
Years Attended
Certificate of Degree Earned
Background History
Have you ever been convicted of any offense other than a violation?

Yes No
If yes, explain below:
Submit photocopies of the following Documents with your Application: (Original Documents will be required for inspection at Interview)

1. New York State Driver License

2. Any other Documents which may be pertinent to the position for which you are applying (EMT/Paramedic Certification, CPR, ACLS, CDL, etc
APPLICANT’S STATEMENT
I certify that all information provided herein is true and complete to the best of my knowledge.

I authorize investigation of all statements and references as may be necessary in arriving at the employment decision.

In the event of employment, I understand that, upon the discovery of false or misleading information given in my application or during my employment interview, discovery of said information may result in my discharge. I also understand that I am required to follow all rules, regulations, policies, procedures, and job requirements of the employer and that my failure to do so may result in my discharge.

I understand that I must be able to fulfill all of the functional job responsibilities as outlined on the New York State Job Description for Emergency Medical Technician – Basic (application pages 2 – 3
Name of Applicant (Print)
Signature of Applicant

Clear
Date

Month Day Year
Date
Please provide us with the following information to assist us in contacting you:
Name:
Position Applied For:
Home Phone:
Cellular Phone:
E Mail Address:
example@example.com
Best Time & Method to Contact You:
Disclosure under Fair Credit Reporting Act and Consent to Procure Consumer Report for Employment Purposes
The undersigned hereby authorizes NDP Emergency Medical Services, or its insurance

agency, Marshall and Sterling, to obtain copies of consumer reports, including a motor

vehicle report, pertaining to me for employment purposes, and for use in rating and/or

underwriting insurance for which the above-named employer may apply, and any renewal
(Signature of applicant/employee)

Clear
(Date)

Month Day Year
Date
Consent to Run Motor Vehicle Abstract
Name as it appears on Driver License
Date of Birth

Month Day Year
Date
License Number
License State
P.O. Box 672 Rhinebeck, NY 12572 (845) 876-0338 (800) 580-2909 Fax (845) 876-7071 www.ndpems.com
BACKGROUND CHECK PERMISSION (COMPREHENSIVE) FOR PROSPECTIVE EMPLOYEE
1. General Consent to Background Investigation

In connection with my application for employment, I give permission to NDP to investigate my personal and employment history. I understand that this background investigation will include, but not be limited to verification of all information on my employment application.

2. Consent to Contact Past Employers

I specifically give permission to NDP to contact all of my prior employers for references. I further give permission to all current or previous employers and/or managers or supervisors to discuss my relevant personal and employment history with NDP, consent to the release of such information orally or in writing, and hereby release them from all liability and agree not to sue them for defamation or other claims based upon any statements they make to any representative of NDP. I further waive all rights I may have under law to receive a copy of any written statement provided by any of my former employers to NDP. I further agree to indemnify all past employers for any liability they may incur because of their reliance upon this agreement.

3. Consent to Contact Government Agencies

I further give permission to NDP to receive a copy of any information obtained in the file of any federal, state, or local court, or governmental agency concerning or relating to me. I further consent to the release of such information and waive any right under law concerning notification of the request for a release of such information. In the event a law does not provide for prospective employers to have access to information, I hereby delegate NDP as my agent for the receipt of information. I understand that the scope of this investigation will be limited as required by applicable law.

4. Cooperation With Investigation

I agree to fully cooperate in NDP’s background investigation, and to sign any waivers or releases that may be necessary or desirable to obtain access to relevant information. In the event that any former employer or federal, state or local governmental agency will not release information or criminal history information directly to the employer, I agree to personally request such information to the extent permitted by law.

This agreement represents the entire understanding and agreement relating to its subject matter. NDP shall be entitled fully to rely on this Agreement. I understand that I have no guarantee of employment and that NDP may determine not to hire me for any lawful reason.
Applicant's Signature

Clear
Date

Month Day Year
Date
Printed Name
P.O. Box 672 Rhinebeck, NY 12572 (845) 876-0338 (800) 580-2909 Fax (845) 876-7071 www.ndpems.com
CONSENT TO DRUG AND/OR ALCOHOL TESTING
I understand it is the policy of NDP for which I am employed or will be employed to conduct drug and/or alcohol tests for the purpose of detecting drug and/or alcohol abuse, and that one of the requirements of employment with the company is the satisfactory passing of the drug and/or alcohol test(s

For the purpose of my continued employment or being further considered for employment, I hereby agree to submit to drug and/or alcohol testing.

I understand that favorable test results will not necessarily guarantee that I will be employed by NDP and is not the only deciding factor of my continued employment. I also understand that a refusal to test can be interpreted as a positive test and can result in disciplinary proceedings up to and including termination of my employment.

I agree to take drug and/or alcohol tests whenever requested by NDP, and I understand that the taking of such tests is a condition of my continued employment.

I also give consent to The WorkPlace of Saint Francis Hospital to release to a designated representative of NDP the results of my tests.

I consent to a drug and alcohol testing as required by and in accordance with the NDP Drug-Free Workplace/Use of Drugs and Alcohol Policy.
Date

Month Day Year
Date
Signature of Employee or Applicant

Clear
Name of Employee or Applicant (Print)
Should be Empty: