Employment Application Form Blackduck Ambulance

Employment Application
Blackduck Ambulance Association Inc. PO Box 400 | Blackduck, MN 56630

We welcome you as an applicant for employment with Blackduck Ambulance Association Inc (BAAI). BAAI will not discriminate on the basis of race, age, religion, national origin, marital status, disability, sex, sexual preference, status with regard to public assistance, or any other basis protected by law. The information contained in this application is considered private data under the Minnesota Data Practices Act, and will be used only in conjunction with your possible employment. Please furnish complete information, so we may accurately and completely assess your qualifications for employment in the position you see. Your application will be evaluated in comparison to the requirements for that position. As an applicant for employment, your name is considered private until you become a finalist for employment with BAAI. You are considered a finalist if and when you are selected for a final interview.
Title of Position applied for:*
Hours Available:*
Wage Desired/$ per hour:*
Employment Status Desired:*

Full TimePart Time
Personal Information
Name:*

First NameMiddle InitialLast NameSuffix
Home Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are 18 years old or older?*

YesNo
Are you legally eligible to work in the United States in the position or which you are applying?*

YesNo
Educational Information

NOTE: If the position you are applying for requires a college degree or other academic credential, you must include a certified transcript from the educational institution that granted you that credential.
High School - Degree Earned*
College - Degree Earned/Course of Study*
Graduate School - Degree Earned/Course of Study*
Technical/Vocational - Degree Earned/Course of Study*
Other
Other

Employment History

List previous employers for the past 5 years, beginning with most recent employer. Please provide all information requested accurately and clearly. Do not use “See Resume” or similar.
Current or Most Recent Employer:*
Supervisor's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Start of Employment*

MonthDayYear
Date
End of Employment*

MonthDayYear
Date
Total Number of Yrs/Mo*
Job Title
Immediate Supervisor(s)
Final Salary*
Specific Duties*
Hours worked per week*
May we Contact this Employer?*
Reason for Leaving or seeking other employment?*
Current or Most Recent Employer:*
Supervisor's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Start of Employment*

MonthDayYear
Date
End of Employment*

MonthDayYear
Date
Total Number of Yrs/Mo*
Job Title
Immediate Supervisor(s)
Final Salary*
Specific Duties*
Hours worked per week*
May we Contact this Employer?*
Reason for Leaving or seeking other employment?*
Current or Most Recent Employer:*
Supervisor's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Start of Employment*

MonthDayYear
Date
End of Employment*

MonthDayYear
Date
Total Number of Yrs/Mo*
Job Title
Immediate Supervisor(s)
Final Salary*
Specific Duties*
Hours worked per week*
May we Contact this Employer?*
Reason for Leaving or seeking other employment?*
Current or Most Recent Employer:*
Supervisor's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Start of Employment*

MonthDayYear
Date
End of Employment*

MonthDayYear
Date
Total Number of Yrs/Mo*
Job Title
Immediate Supervisor(s)
Final Salary*
Specific Duties*
Hours worked per week*
May we Contact this Employer?*
Reason for Leaving or seeking other employment?*

Reference 1
Name:*

First NameLast Name
Relationship to you*
Occupation*
Years Known:*
Phone Number*

Area CodePhone Number
Reference 2
Name:*

First NameLast Name
Relationship to you*
Occupation*
Years Known:*
Phone Number*

Area CodePhone Number
Reference 3
Name:*

First NameLast Name
Relationship to you*
Occupation*
Years Known:*
Phone Number*

Area CodePhone Number

Knowledge/Skills/Abilities

List an other courses, seminars or training you have that may provide you with skills related to this position:
Typing Ability?*

YesNo
Computer Experience?*

YesNo
Computer software program knowledge
Office equipment you can operate
Special training
Courses, seminars, workshops
Registrations, licenses and certificates
If relevant to the position
Date Issued:

MonthDayYear
Date Expired:

MonthDayYear
Date
If relevant, list other registrations, licenses and certificates you have.
Date Issued:

MonthDayYear
Date Expired:

MonthDayYear
Date
For Labor and Skilled Trades only
List the equipment you are capable of operating
Additional information:
Info you deem relevant to better assess your suitability for the position applied for.

Volunteer Experience

Describe any unsalaried or volunteer experience relevant to the position for which you are applying.
Volunteer experience
Military Experience
Did you serve in the U.S. Armed Forces?

YesNo
Describe your duties:
Do you wish to apply for veteran's preference points?

YesNo
If you answered “yes,” you must complete the enclosed application for veteran’s preference points, and submit the application and required documentation to BAAI within seven days of the application deadline for the position for which you are applying.
Convictions

If you have been convicted of any violations, other than parking tickets, list all convictions within the last 15 years. Do not list juvenile (under 18 years of age) convictions unless you were tried as an adult. BAAI does not automatically reject applicants who have conviction records. Provide Month/Day/Year of conviction, City/State of conviction, Nature of Offense, and Result.
Past Convictions or violations
Authorization
I authorize that a transcript may be requested where necessary to verify any education record. I hereby expressly authorize the collection, use and release of any and all information concerning me, which relates to my employment. I hereby release BAAI, with which I am seeking employment, from any liability, which may result from releasing information requested. I also expressly authorize the release by my present and past employers, including its agents/employees of any and all information concerning my employment with them, in any form, oral or written, and I agree to hold harmless my present and past employers from any liability whatsoever arising out of its release of information pursuant to this release.

I understand that if offered a position, and depending on the position, I may be required to submit to and pass a psychological examination, a physical examination, and /or a physical agility test.

I hereby certify that all answers contained in this application are true and I agree and understand that any misrepresentation or omission of facts contained in this application will be grounds for disqualification for employment or in the event of employment, dismissal from employment upon discovery of the information.
By signing this form I hereby acknowledge I have read and understood the above statements. Failure to sign below may result in reject of your application.

Accept
Should be Empty:

Employment Application

Blackduck Ambulance Association Inc. PO Box 400 | Blackduck, MN 56630

Personal Information

Educational Information

Employment History

Reference 1

Reference 2

Reference 3

Knowledge/Skills/Abilities

Volunteer Experience

Military Experience

Convictions

Authorization