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Personal Information

Date: Email*:
Last Name*: First Name*: Middle Name: Maiden Name: Primary Phone*:
Address*: City*: State*: Zip*: Secondary Phone:
If you are under 21, please list your age: Best time to be reached: Other Phone:
   

Position Desired

What position(s) are you applying for?*    
 EMT EMT/I Paramedic Dispatch Wheelchair Marketing Business Office
Employment desired:      
 Full-Time Only Part-Time Only Full or Part-Time
How many hours can you work weekly? Min Hrs: Max Hrs:  
Can you work weekends?  Yes No Can you work nights?  Yes No
Are you available to work immediately?  Yes No If no, when?
Have you ever worked for Bay Star before?*  Yes No    
Have you ever been forced to resign for misconduct or unsatisfactory performance?*  Yes No    
Have you ever convicted of a crime?*  Yes No    
Have you ever had any DWI/DUI convictions?*  Yes No    

Certifications

(Check All that Apply):
 ACLS PHTLS PPPC CPR BTLS NALS PALS ABLS HAZMAT EVAC
 ACLS/I PHTLS/I PPPC/I CPR/I BTLS/I NALS/I PALS/I ABLS/I
List any other certifications:
What state did you get your EMS Licence?
EMS License Number:

Employment Record

List below all present and past employment, beginning with the most recent.
Business Name: Supervisor's Name: Phone:    
   
Address: City: State: Zip:  
 
Last Job Title: Work Performed:      
     
Dates of Employment Salary Start: Salary End:  
to $ $  
May we contact this employer? Reason for leaving: Were you terminated?
 Yes No  Yes No
Business Name: Supervisor's Name: Phone:    
   
Address: City: State: Zip:  
 
Last Job Title: Work Performed:      
     
Dates of Employment Salary Start: Salary End:  
to $ $  
May we contact this employer? Reason for leaving: Were you terminated?
 Yes No  Yes No
Business Name: Supervisor's Name: Phone:    
   
Address: City: State: Zip:  
 
Last Job Title: Work Performed:      
     
Dates of Employment   Salary Start: Salary End:  
to $ $  
May we contact this employer? Reason for leaving: Were you terminated?
 Yes No  Yes No

Additional Information

Is there any additional information you would like us to know?

Resume

Resume (If Available): Acceptable File Types: PDF or DOC

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Bay Star Ambulance Service, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Bay Star, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Manager of Bay Star. Both the undersigned and Bay Star may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Bay Star may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Bay Star permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Bay Star from any liability as a result of such contract.

I also understand that (1) Bay Star has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, Bay Star may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, Bay Star, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with Bay Star shall be probationary for a period of Ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with Bay Star is terminable at will for any reason by either party.
I understand that Bay Star does subscribe to Workmen’s Compensation. I understand that if I am injured while working for Bay Star, I must notify a supervisor within 24 hours of being injured. I, also understand that if a physician places me on light duty, Bay Star will not be required to provide light duty to me.

I understand that Bay Star will not tolerate sexual or any other form of unlawful harassment. I understand that I have the affirmative obligation to report it. I also understand that unlawful harassment is grounds of disciplinary action up to and including immediate dismissal.

 I have read and understand the statement above.


Bay Star Ambulance Service is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Bay Star Ambulance Service depends solely on your qualifications.

Thank you for completing this application form and for your interest in Bay Star Ambulance Service. Your application for employment will be maintained in our Human Resources Department for twelve (12) months.