BROOME VOLUNTEER VOLUNTEER EMERGENCY SQUAD

Broome Volunteer Emergency Squad

PO BOX 599 * Binghamton, New York 13902 Buisness (607) 772-6565 * Fax (607) 772-7154

PLEASE NOTE: It is important that you complete all parts of the application. If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted. If you have no information to enter in a section, please write N/A.

Name First MI Last

Social Security Number

Mailing Address

City State and Zip Code

Email

example@example.com

Telephone

Day/Hours available to Work

I am Seeking a:

Full-timePart-timeVolunteer

How many hours can you work weekly?

Can you work nights?

Date available to begin?

Date

Have you ever been employed by this organization in the past?

YesNo

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.

YesNo

Have you ever been convicted of, or entered a plea of guily, no contest, or had a withheld judgement to a felony?

YesNo

If Yes please explain:

Do you have a driver's license?

YesNo

Drivers license number

Issued in what state?

Have you had any accidents during the past three years?

How many?

Have you had any moving violations during the past three years?

How many?

Education

High School

Location (mailing address)

Years Completed

Degree

College 1

Location (mailing address)

Years Completed

Major

Degree

College 2

Location (mailing address)

Years Completed

Major

Degree

Volunteer Experience

Company

Location (mailing address)

Years Completed

Company 2

Location (mailing address)

Years Completed

Company 3

Location (mailing address)

Years Completed

Have you ever been in the Armed Forces?

YesNo

Are you now a member of the National Guard?

YesNo

Date entered

Date

Discharge date

Date

Please list ALL work experience beginning with your most recent job held. Attach additional sheets if necessary.

Company

Address

City, State, Zip

Name of last supervisor

Hrsweek

Start Date

Date

End Date

Date

Your last job title

Phone Number

Reason for leaving

May we contact this employer?

YesNo

List the jobs you held duties performed skills used or learned advancements or promotions while you worked at this company

Company

Name of last supervisor

Hrsweek

Address

City State and Zip Code

Start Date

Date

End Date

Date

Your last job title

Phone Number

Reason for leaving

List the jobs you held duties performed skills used or learned advancements or promotions while you worked at this company

May we contact this employer?

YesNo

Company

Name of last supervisor

Hrsweek

Address

City State and Zip Code

Start Date

Date

End Date

Date

Reason for leaving

Your last job title

Phone Number

List the jobs you held duties performed skills used or learned advancements or promotions while you worked at this company

May we contact this employer?

YesNo

Please include name, phone number, and circumstances of your acquaintance. Exclude relatives and former employers.

1

2

Certifications

EMS Certification

Certification Number

Expiration Date

Date

CPR, ACLS, PALS

Expiration Date

Date

CPR, ACLS, PALS

Expiration Date

Date

CPR, ACLS, PALS

Expiration Date

Date

I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated.

Signature

Date

In connection with my application for membership or employment (including contract for services with Broome Volunteer Emergency Squad), I hereby understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions, and revocations.

I (name) authorize without reservation any party or agency to furnish the above-mentioned information.

I have the right to obtain information as to the name, address, and phone number of any agency providing such infromation and further, may request of that agency, upon proper identification, the name and substance of all information as well as the recipients of any reports on me which the agency has previously furnished within the two (2) year period preceding my request. This Authorization shall remain on file and shall serve as ongoing authorization for the organization to procure Motor Vehicle Reports at any time during my employment, membership, or contact period.

Print

Signature

BROOME VOLUNTEER VOLUNTEER EMERGENCY SQUAD

BROOME VOLUNTEER EMERGENCY SQUAD INC