Boonsboro Ambulance & Rescue, Inc.

Career Personnel Application

Boonsboro Ambulance & Rescue, Inc.
Certification Level
Type of Employment
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
City of Birth
Social Security
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Driving Record
Driver's License Number
Issuing State
Class of License
If you checked any of the boxes in the above selections, explain the circumstances below:

Certification Information
The following postiion are required for all position. Check each current certification that you possess:
If you are applying for a BLS position, you must have the following certifications:
If you are applying for an ALS position, you must have one of the following certification:
If you checked the boxes to any of the above two questions, explain below:
List any additional certifications, licenses, of skills that you possess:
Do you have any other skills or abilities that you believe would be a benefit to the position applied for?

References
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:

Employment History

Complete the information for your last 3 jobs, starting with the most recent
Employer # 1
Address

Street Address

Street Address Line 2

CityState

Zip Code
Position/Title
Job Description
Employed From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employed To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
Supervisor Name & Phone Number
Employer # 2
Address

Street Address

Street Address Line 2

CityState

Zip Code
Position/Title
Job Description
Employed From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employed To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
Supervisor Name & Phone Number
Employer # 3
Address

Street Address

Street Address Line 2

CityState

Zip Code
Position/Title
Job Description
Employed From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employed To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
Supervisor Name & Phone Number

Education
High School
Graduation Year
College
Years Complete
Trade/Technical School
Years Complete
Military Service
Branch
Rank
Dates of Enlistment
Specialty

Medical History

The duties of the position at Boonsboro Ambulance & Rescue are strenuous, enplanned, and mentally as well as physically stressing. You must be able to perform the duties of the position in all types of weather, in stressful situations, and at all hours of the day.
If you have any medical, physical, or emotional limitations, please explain

"Under Maryland Law an employer may not require or demand any applicant for any employment or prespective employment or any any employee to submit to or take a polygraph, lie detrector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $1,000.00."
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that the information contained is correct to the best of my knowledge and understand that falsification of misrepresentation is grounds for dismissal or rejection of this application.

I expressly authorize and consent Boonsboro Ambulance & Rescue Service, Inc. to conduct work history, credit check, reference and police records inquiries as it deems appropriate. If hired, I understand that as part of the criminal background investigation required by Maryland law, I may be fingerprinted. Continued employment may be contingent on the results of this investigation.

I authorize all references listed in this application to give any and all information that they may have, and release all partiesfrom liability for any damages that may result from furnishing same to you.

In consideration of my employment, I agree to conform to the rules and regularions of Boonsboro Ambulance & Rescue Service, Inc. and my employment and compensation may be terminated, with or without cause, and with or without notice, at any time, at the option of either the company or myself, and without notice or liability for wages or salarty except such earned at the date of such termination.

Boonsboro Ambulance & Rescue Service, Inc. is a private, non-profit corporation, chartered by the State of Maryland to provide emergency services in Washington County, Maryland. Boonsboro Ambulance & Rescue, Inc. is an equal opportunity employer hires without regard to race, sex, creed or sexual orientation. If you believe your civil rights have been violated in this hiring process, contact the State Labor Relations Board.
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Career Personnel Application

Driving Record

Certification Information

References

Employment History

Education

Military Service

Medical History