WAS Co5 Application

Waterford Ambulance Service, Incorporated
Employment Application
Position (s) Applied For: Date:

Applicant Information:
Full Name:
Address:
City: State: Zip:
Phone: ( ) Email: Social Security #:
Have you ever filled out an application with this company before? Yes No
If yes, when?
Have you ever worked for this company before? Yes No
If yes, when?
Reason for leaving?
Are you a citizen of the United States? Yes No
Are you now legally allowed to work in the United States? Yes No
Date available to start:
Do you have a valid driver’s license?: Yes No
If yes, Driver’s License Number: State:
Are there any restrictions on your ability to operate a motor vehicle? Yes No
Do you have a valid Connecticut Commercial Driver’s License? Yes No
Have you ever pled “guilty” , “no contest” or been convicted of a crime? Yes No
If yes, give dates and details, including city, county and state of conviction:
Answering “yes” to these questions does not constitute an automatic rejection for employment. Date of offense,
seriousness, and nature of violation, rehabilitation, and position applied for will be considered.
Cohanzie Co 5
Applicant name:
Specialized Job Requirements:
Do you currently hold any specialized licenses or certifications? Yes No

If yes, please specify:
Title: Number: State: Expiration Date:
Education:
High School: Address:
# of years completed: Did you graduate? Yes No
College/University: Address:
# of years completed: Did you graduate? Yes No Degree:
Summerize your special skills or qualification:

(You may attach your Resume in lieu of filling out this section, but the Resume must contain a summary of skills
and/or qualification.)
Copies of any certifications ( CPR, EMT, EMR, etc.) CT Driver’s License, NIMS Certifications
(IS 100 & 700), Driving History and CT Background Check must be included with application.
Cohanzie Co 5
Applicant name:
Previous Employment
(Start with your present or last jobs; include any job-related military service assignments and volunteer
activities. Attach additional sheets if necessary. You may attach your Resume in lieu of filling out this
section):
No applicant will be considered until all information requested below has been provided.
Date of Employment: From / / To / / Position(s) Held:
Company:
Address:
Phone: ( ) Supervisor: Title:
Responsibilities:
Reason for leaving:
May we contact this empolyer for a reference? Yes No
Date of Employment: From / / To / / Position(s) Held:

Company:
Address:
Phone: ( ) Supervisor: Title:
Responsibilities:
Reason for leaving:
May we contact this empolyer for a reference? Yes No
References:
Please furnish the names, addresses and telephone numbers of two people to whom you are not related and
by whom you have not been employed:
Full Name:
Address:
City: State: Zip: Phone:( )
Full Name:
Address:
City: State: Zip: Phone:( )
Cohanzie Co 5
Applicant’s Statement
The information that I have provided on this application is true and complete to the best of my knowledge. I
understand that any misrepresentation or omission of any fact or circumstance in my application, resume, or
any other materials I have completed or submitted or made during any of my interviews may be justification
for refusal of employment or if employed, termination of employment. Any offer of employment I may receive
is contingent upon my successful completion of the total pre-employ-ment screening process, including your
receipt of references which you consider satisfactory and my satisfactory completion of any pre-employment
physical examination which you may require.
In processing my application for employment, I authorize Waterford Ambulance Service, Inc. to verify
all the information provided by me and obtain a consumer or investigative consumer report concerning,
amoung other things, current and prior employment, credit history, driving record, military record,
education, character, general reputation, personal characteristics and criminal record. I understand that
a report may be based on telephone or personal interviews with my present and former employers and
others. I understand that I have the right to make a wrtitten request to Waterford Ambulance Service,
Inc. to verify all the information provided by me and obtain a consumer or investigative consumer report
concerning, Waterford Ambulance Service, Inc. as to whether a consumer report or an investigative
consumer report was procured and to request a complete and accurate disclosure of the nature and scope
of the report.
I authorize and request all of my present and former employers to furnish information about my employment
record, including the reason(s) and circumstance(s) for my termination of my employment, work perfor-mance,
qualifications, abilities and other qualities pertinent to my qualifications for my employment, including
character, general repuatation and personal characteristics. I hereby release employers, schools or persons from
all liability when responding to inquires in connection with my application.
I understand that employment at Waterford Ambulance Service, Inc. is “at will” and that if I am hired my
employment and compensation can be terminated with cause or notice, at any time, at the option of either
Waterford Ambulance Service, Inc. or myself. I further understand it can be terminated with cause due to failure
to; follow Waterford Ambulance Service policy, procedure, directives, or written/verbal directions.
I will keep current with Waterford Ambulance Service my; primary EMS district, address, EMS/PowerDMS
email address, contact phone number, and licensure.
I HAVE READ AND UNDERSTAND THE ABOVE,
Signature Date
For Human Resource Use Only

Arrange Interview Yes No
Remarks:
Interviewers: Date
Employed Yes No Date of Employment
Interviewers Signature & Title Date
Please Mail to: Waterford Ambulance Service, Inc. c/o Secretary, P.O Box 137, Waterford, CT, 06385
Cohanzie Co 5

WAS Co5 Application

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Waterford Ambulance Service, Incorporated

Position (s) Applied For: Date:

Have you ever worked for this company before? Yes No

Are you a citizen of the United States? Yes No

Date available to start:

Do you have a valid driver’s license?: Yes No

If yes, Driver’s License Number: State:

Specialized Job Requirements:

Do you currently hold any specialized licenses or certifications? Yes No

Summerize your special skills or qualification:

Date of Employment: From / / To / / Position(s) Held:

I HAVE READ AND UNDERSTAND THE ABOVE,

For Human Resource Use Only

Employed Yes No Date of Employment

Interviewers Signature & Title Date

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