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May we use your employer as a reference?
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Business References
Provide two verifiable business references whom you have known for at least two years.
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Business Reference #1 Phone
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Business Reference #1 Address
How long has Business Reference #1 known you?
Business Reference #2 Name
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Business Reference #2 Phone
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Business Reference #2 Address
How long has Business Reference #2 known you?
Personal References
Provide one verifiable personal references whom you have known for at least two years:
Personal Reference #1 Name
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Personal Reference #1 Phone
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Personal Reference #1 Address
How long has Personal Reference #1 known you?
About You
Do you have any health limitations which would impair your ability to perform routine physical corps duties, such as lifting and moving patients and equipment?
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No
If yes, Explain
Driving Experience
Do you hold a current valid NY State driver's license?
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No
If yes, what class?
License Expiration Date
Have You Been Cleared to Drive an Ambulance with Another Service?
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Have You Taken any Formal Emergency Driver Training
Yes, list below
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Formal Driving Training Courses:
A Few Final Questions..
Who referred you to us for employment?
Have you ever been convicted of a felony?
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Please explain. Did you receive a certificate of relief from disability
Why do you want to work for Nyack Community Ambulance Corps?
Special skills in emergency medicine that would be applicable to employment?
Do you have a minimum of 3 years experience in emergency medicine?
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If yes, list all pertinent certifications:
List your general availability for work:
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I agree
I certify by typing my name below that all of the information that I have provided is true to the best of my knowledge; I give permission to Nyack Community Ambulance Corps to do a personal check on the information provided
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