Volunteer Application

Transcription

1 Vlunteer Applicatin Please answer all questins. If a questin des nt apply, please put N/A in the blank. If yu need additinal space yu may add infrmatin in the cmments sectin at the end f the applicatin. The intentinal missin f infrmatin n this applicatin shall be sufficient cause fr terminatin f emplyment. Applicatins will remain active fr 60 days and after that time must be re-submitted. Applicatin Date: I am applying fr a psitin as a: CPR Certified Driver EMT Name Scial Security # (First, Middle & Last) Date f Birth: Age: Physical Address: City State Zip Cde Mailing Address if Different: Hme Phne: Cell Hw were yu referred t the Nrth Frk Ambulance? Website Advertisement Open Huse Public Event Vlunteer If yu were referred t the Assciatin by a current vlunteer what was the vlunteer s name? Have yu ever been emplyed by the Nrth Frk Ambulance Assciatin? Yes N f Service: Licenses and/r EMT Certificatins Held: Current AHA CPR fr Healthcare Prfessinals Certificatin? Yes N If yes, Expiratin Date: EMT Certificatin Level: EMT Certificatin Number: State f Issuance: Expiratin Date: If yu are an EMT, is yur Natinal Registry Certificatin current? Yes N Describe any Advanced Levels f Training: Have yu ever had a Healthcare license r EMT certificatin revked r suspended? Yes N If yes, please explain: Driver s License Infrmatin: D yu have a valid State f Clrad Driver s License? Yes N If n, yu must btain ne within 60 days f date f hiring. Current Driver License Number: What classificatin f license d yu hld? Class R CDL-A CDL-B If yu answer Yes t any f the fllwing Questins related t yur license, yu MUST prvide explanatins in the Cmments Sectin. Has yur license been suspended, revked r cancelled within the past year? Yes N. In the past year, have yu received a mving vilatin? Yes N. If yes Hw many citatins/summns? Have yu ever been arrested fr and/r cnvicted f Driving Under the Influence (DUI) f Alchl and/r Drugs? Yes N

2 Criminal Histry: If yu answer yes t any f the questins in this sectin yu must prvide a cmment fr each questin in the cmments sectin. Hw lng have yu lived in the State f Clrad? Date yu began living in CO if less than ne year Have yu ever been cnvicted f a misdemeanr? Yes N Have yu ever been cnvicted f a Felny? [ ] Yes [ ] N Have yu ever been cnvicted f Assault, Burglary r theft? Yes N Cmments fr Driver s License/Criminal Histry: Emplyment Histry: Beginning with yur mst recent r current emplyer, please list the three mst recent jbs yu have held. If yu have had n previus emplyment, please prvide us with a list f nn-family references. Emplyer: Telephne: Emplyed: Name f Supervisr: cntact? Yes N Psitin yu held: Reasn fr Leaving: Briefly describe yur duties in this psitin and hw they relate t vlunteering with the Nrth Frk Ambulance: Mdified: 3/17/14 Nrth Frk Ambulance Vlunteer Applicatin Page 2 f 5

3 Emplyer: Telephne: Emplyed: Name f Supervisr: cntact? Yes N Psitin yu held: Reasn fr Leaving: Briefly describe yur duties in this psitin and hw they relate t vlunteering with the Nrth Frk Ambulance: Emplyer: Telephne: Emplyed: Name f Supervisr: cntact? Yes N Psitin yu held: Reasn fr Leaving: Briefly describe yur duties in this psitin and hw they relate t vlunteering with the Nrth Frk Ambulance: Have yu ever been discharged frm emplyment r asked t resign? Yes N If yes, Date f discharge: Emplyer: Please explain: Mdified: 3/17/14 Nrth Frk Ambulance Vlunteer Applicatin Page 3 f 5

4 Educatin: Please list all educatinal institutins starting with high schl, which yu have attended, cncluding with the highest level f educatin attempted r cmpleted. High Schl: Did yu graduate frm high schl? Yes N Did yu earn a GED? Yes N N/A Name f High Schl / GED Training Center: Physical Address: State: Zip: Trade/Technical Schl: Name f Institutin: Physical Address f Institutin: State: Zip: Curse f Study: Did yu Graduate? Yes N Cllege/University: Name f Institutin: Physical Address f Institutin: State: Zip: Curse f Study: Minr: Did yu Graduate? Yes N Date f Graduatin: Cllege/University: Name f Institutin: Physical Address f Institutin: State: Zip: Curse f Study: Minr: Did yu Graduate? Yes N Date f Graduatin: Mdified: 3/17/14 Nrth Frk Ambulance Vlunteer Applicatin Page 4 f 5

5 Other Specialized Training: Name f Institutin: Physical Address f Institutin: State: Zip: Curse f Study: Certificate/Certificatin/Licensure Received: Please Read the Fllwing Statement Carefully Befre Signing By signing this applicatin, I certify that all infrmatin cntained herein is true and cmplete t the best f my knwledge. I understand that any false infrmatin r missin may disqualify me frm further cnsideratin fr emplyment and may result in dismissal if discvered at a later date. I authrize the investigatin f any and all statements cntained within this applicatin. I als authrize, whether listed r nt, any persn, schl, current emplyer, past emplyer, and rganizatins t prvide relevant infrmatin and pinins that may be useful in making a hiring decisin. I release such persns and rganizatins frm any legal liability in making such statements. Emplyment with the Nrth Frk Ambulance Assciatin is at-will. Either the emplyee r management has the right t terminate the emplyment at any time, fr any reasn. I, (print name) understand that a criminal backgrund check will be perfrmed thrugh the Clrad Bureau f Investigatin (CBI), and further acknwledge that I have read and understand the abve-mentined statements, by my signature cnsent t these statements. [ ] By checking this bx, yu acknwledge yu have read and agree t abide by the minimum requirements fr either the EMT r CPR Certified Driver psitin fr which yu are applying as utlined n Applicant s Signature Date THANK YOU FOR YOUR TIME AND DESIRE TO VOLUNTEER. PLEASE SUBMIT YOUR APPLICATION PER THE INSTRUCTIONS OUTLINED ON - REMEMBER TO SUBMIT YOUR DMV DRIVING RECORD WITH YOUR APPLICATION. If cmpleting electrnically, yu may submit with an electrnic signature. Yu acknwledge by ding s that yur electrnic signature is the same as yur physical signature and yu may be asked t sign a hard cpy f the applicatin t be kept n file by the Bard f Directrs. The Nrth Frk Ambulance is an Equal Opprtunity Emplyer Mdified: 3/17/14 Nrth Frk Ambulance Vlunteer Applicatin Page 5 f 5