Waterbury Ambulance Service Application

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Waterbury Ambulance Service Application

First Name*

Last Name*

Email Address*

Cell Phone

Address, line 1*

Address, line 2

City*

State*

Zip Code*

Date of Birth

Emergency Contact*

Level of Certification

Other Relevant Certifications

Driver's License Number

Highest Level of Education Completed

What position are you interested in at Waterbury Ambulance?

Full Time ALS Provider Part Time ALS Provider Per Diem ALS Provider Volunteer BLS Provider Volunteer Driver Backcountry Rescue Volunteer Must Live in Waterbury Area

Previous Work Experience

Availability

Healthcare Experience

Describe your goals in this position.

Reference #1

Reference #2

Reference #3

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.

I agree:

Yes No

Social Security Number?

Did anyone refer you for this position?

Any other information you would like to share?

Waterbury Ambulance Service is committed to fostering a culture of diversity and inclusion, embracing differences in age, ethnicity, gender, and other characteristics. The organization's diversity initiatives encompass recruitment, selection, compensation, professional development, and community engagement to promote equity and respect for all individuals.

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Waterbury Ambulance Service Application

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