Return to Home Page

EMPLOYMENT APPLICATION

This application may be printed, completed and submitted
By Mail: Mr. Daryn Baia, Empress Ambulance Service, 722 Nepperhan Ave, Yonkers NY, 10703 By Fax: 914-965-9776

Empress Ambulance Service will consider applicants for all positions equally without regard to age, gender, race, color, national origin, religion, creed, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position Applied For: ________________________________ Date of Application: ______________

Name (Last, First, Middle)

Social Security #

ADDRESS INFORMATION:

Address Apt #			Phone #
City	State	Zip Code	Alternate Zip Code

PREVIOUS ADDRESS: During the last three years, beginning with most recent.

Address Apt #			Phone #
City	State	Zip Code	Alternate Zip Code

EMERGENCY CONTACT INFORMATION:

Name (Last, First)			Relation
Address Apt #			Phone # (include area code)
City	State	Zip	Alternate Phone #

GENERAL INFORMATION

Are you currently employed? Yes No Date you can begin work: _______

May we contact your present employer? Yes No

Are you available to work: Full Time Part Time Per Diem Temp Nights Weekends

Have you ever filed an application with us before? Yes No If Yes, give date: ______________

Have you ever been employed with us before? Yes No If Yes, give date: ______________

Are you under 18 years of age? Yes No If yes, date of birth: ____________

Have you ever been convicted of a felony? Yes No

If Yes, give details: ______________________________________________________________________

______________________________________________________________________________________

I am a U.S. citizen or National of the U.S., an alien Lawfully

admitted for permanent residence, or otherwise authorized to work in the U.S. __ Yes __No

EDUCATION

	Name of School	Address	Years Completed	Graduated Yes/No	Major/Type of Degree
High School
College
Graduate or Professional
Technical/Trade Or Other

Are you attending school? Yes No Number of credit hours: _______ Where?________________________

am am am am am am am am am am
Schedule: Mon__ pm to __ pm Tue__ pm to __ pm Wed__ pm to __ pm Thu__ pm to __ pm Fri__ pm to __ pm

PREVIOUS EMPLOYMENT

Start with your present or last job. Include any job-related volunteer activities. You may exclude organizations that indicate race, color, national origin, disability, sexual or religious orientation, or any other protected status.

1	Employer	Dates Employed		Job Title
		From	To
	Address			Supervisor
	City, State, Zip	Salary/Hourly Wage		Reason for Leaving
		Starting	Final
	Telephone Number
2	Employer	Dates Employed		Job Title
		From	To
	Address			Supervisor
	City, State, Zip	Salary/Hourly Wage		Reason for Leaving
		Starting	Final
	Telephone Number
3	Employer	Dates Employed		Job Title
		From	To
	Address			Supervisor
	City, State, Zip	Salary/Hourly Wage		Reason for Leaving
		Starting	Final
	Telephone Number
4	Employer	Dates Employed		Job Title
		From	To
	Address			Supervisor
	City, State, Zip	Salary/Hourly Wage		Reason for Leaving
		Starting	Final
	Telephone Number

Are there any employers you DO NOT wish us to contact? ____________________________________

Have you ever been discharged by a previous employer? Yes No If Yes, when? ______________

Give details: _________________________________________________________________________

____________________________________________________________________________________

US MILITARY SERVICE

Yes No Branch ______________ Induction Date:________ Discharge Date:_______ Rank:_____

Specialty:__________________________ Service Schools:___________________________________

DRIVERS LICENSE INFORMATION

State: _______________ License #: ______________________ Class: _________ Years Driving: ____

	Driving Violations(List all received within the past 3 years)	Date	Disposition and Fine
1
2
3
4
5

	Automobile Accidents:	Date	Location
1
2
3

PROFESSIONAL CERTIFICATIONS

List all applicable certifications and professional or military training received

	Course:	Certification #	Date	Expires	Course Location
1
2
3
4
5
6

List below any additional training or apprenticeships, activities or offices held, language, computer or
specialized skills, or any other information you feel would be helpful to us in considering your application:

____________________________________________________________________________________

PERSONAL REFERENCES (other than relatives)

Name	Address (include city, state, zip)	Phone
1
2
3

APPLICATION AGREEMENT

In completing this application for employment, and any supplements to this application, I certify that information given herein is true
and complete to the best of my knowledge. I understand that misrepresentation or omission of facts is cause for cancellation of this
application or separation from the company’s service if I am employed I understand also, that I am required to abide by all rules and
regulations of the employer. I agree that Empress shall not be liable in any respect if my employment is terminated because of the
falsity of statements made by me on this application.

I authorize investigation of all statements contained in this application as may be necessary for arriving at an employment decision.
I understand that information concerning my past record will be sought from my previous employers and other sources and I hereby
release from all liability or damages those individuals, corporations, or organizations who provide such information. I understand that
any such information provided shall become the exclusive property of the company.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the company is
of an ‘at will’ nature, which means that I may resign at any time and Empress may discharge me at any time with or without cause.
I further understand that this ‘at will’ relationship may not be changed unless specifically agreed to in writing by an authorized executive
of this company.

This certifies that this application was completed accurately and honestly by me or at my direction.

APPLICANT’S SIGNATURE ____________________________________________ DATE ____________