Waterbury Ambulance Service
Job Application
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone (or Main Number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Do you live in the Waterbury Area?
Job Position & Availablility
What position are you interested in at Waterbury Ambulance?
*
Please Select
Full Time Paramedic
Part Time ALS Provider
Per Diem AEMT
Per diem Paramedic
Per Diem EMT
Volunteer EMT/AEMT/Paramedic
Volunteer VEFR/EMR
Volunteer Backcountry Rescue (Must live in Waterbury Area)
Shift Availability (check all that apply)
*
Week Days
Weekends
Holidays
Overnight Hours
What does your ideal schedule look like and what are your goals in this position?
Certifications & Licenses
Include state and #
Drivers License #
Include state and # please
Level of Certification
*
Please Select
AEMT - Advanced Emergency Medical Technician
Critical Care Paramedic
EMR - Emergency Medical Responder
EMT - Emergency Medical Technician
Paramedic
VEFR - Vermont Emergency First Responder
WFR - Wilderness First Responder
I am not certified, but I want to be
Other Relevant Certifications
ACLS, PALS, BLS, CPR, etc.
Highest Level of Education
Please Select
High School
Technical College Certification Program
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
Work Experiences
How many years have you been in the healthcare field?
Healthcare Experience
Describe your experience working in healthcare/prehospital emergency care
Previous Work Experiences
List your previous work experience including positions held, employers, date of employment.
Please upload your your resume
*
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References
Did anyone refer you to us?
Reference #1
*
Include name, position and contact info
Reference #2
Include name, position and contact info
Reference #3
Include name, position and contact info
Any other information you'd like to share?
Authorization for Background Check
I am applying for employment/membership with Waterbury Ambulance Service. As a part of the application process, I understand that Waterbury Ambulance Service will conduct a background and reference check which may include a review of public records, criminal history check, child/elder abuse clearance screenings (as applicable) and inquiries of my former employers and references which I have provided regarding my qualifications and suitability for employment/membership, as well as verification of any information I have provided in this application. As part of this inquiry, I understand that Waterbury Ambulance Service will obtain a report of criminal history information, child/elder abuse clearances (as applicable) and driver’s license history, from applicable law enforcement agencies, or, in some cases, the Federal Bureau of Investigation, and that applicable state law may prohibit the employment of persons convicted of certain crimes.I hereby give my permission to any of my listed references to release to Waterbury Ambulance Service any information regarding my work and volunteer experience, including, but not limited to performance of expected duties and disciplinary information, to Waterbury Ambulance Service.I hereby authorize Waterbury Ambulance Service to conduct this background and reference check, as well as a drug and alcohol screen as part of the application process, and I release from liability Waterbury Ambulance Service and its representatives for seeking, gathering, and using such information. I also release any individual or entity from any liability whatsoever for providing Waterbury Ambulance Service with any information concerning my qualifications and suitability for employment or membership, including the former employers and personal references I have identified on the application.I authorize Waterbury Ambulance Service to send a copy of this authorization to my listed references or anyone else contacted by the Company to provide information about me.
Do you agree to a background check?
*
Yes
No
Signature
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Submit
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