Employment Application

Your Information

Name

Address

City

State

Zip

Home Phone

Cell Phone

Email


Position Applying For

Employment Type

Date Available To Start Work


Have you ever been convicted, plead guilty, or nolo contendere (no contest) to a felony or misdemeanor, including DUI, or other traffic violations?
YesNo

If "Yes" please explain

Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid?
YesNo

If "Yes" please explain

Do you have a current driver’s license?
YesNo
License Number:

Have you had a valid driver license for at least 3 years?
YesNo

Are you under 21 years old?
YesNo

Current Pennsylvania DOH certification level

DOH Certification Number

Education

Please include all your education levels, schools attended, dates complete and GPA.

EVOC Date Completed

EMT/EMT-P

ACLS

CPR

PALS

Other Education


Employment History

Please include employer name, dates, starting and ending wages, supervisor and reasons for leaving

Volunteer Activities
Volunteer activities (Fire/EMS/Rescue experience, include company name, dates, positions held):

By submitting this application, you aI verify that all information contained in this application is true and correct. I shall provide Noga Ambulance Service any changes to this information.

I understand that any false or incomplete information may be grounds for dismissal from employment from Noga Ambulance Service.

I authorize Noga Ambulance Service to investigate all statements made in this application and in support of this application.

I authorize Noga Ambulance Service to obtain and review such documents from other services and third parties.

I authorize third parties to provide such information and documents to Noga Ambulance Service, to assist said company in evaluating my professional competence and qualifications, including my character and ethical standards, my ability to work cooperatively with others, my physical and mental health and my emotional stability.

I release Noga Ambulance Service, its officers, employees and agents from any and all liability in conducting such an investigation.

I release all individuals, corporations and organizations from any and all liability who provide information, including otherwise privileged information relating to this application.

Noga Ambulance Service, Inc may require applicants to demonstrate that they can perform the essential functions of our job to include lifting as part of the application process. A copy of a job description will be provided to you upon request or if you are extended an opportunity to enter the interview process. Applicants who are offered a position with Noga Ambulance Service, Inc. will be offered that position contingent upon successful completion of a job-related physical examination, which may include drug testing, and contingent upon our insurance carrier approving you to operate Noga Ambulance Service vehicles.

Noga Ambulance Service, Inc. considers applications for employment without regard to race, color, religion, sex, national origin, age (over 40), disability, veteran status, or any other characteristic protected by law.