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First Name
Last Name
Email
Phone Number
Highest level of education
Current Employer
Business Phone Number
Institution Name
Type of Business
Immediate Supervisor
MEMS License #
License Level
Address
Field of Study
Current Positon
Dates Attended
Date Started
Position Duties
Reason for leaving (if applicable)
Previous Employer
Business Phone Number
Type of Business
Immediate Supervisor
Position held at departure
Dates Employed
Position Duties
Reason for Leaving
Previous Employer
Business phone number
Type of Business
Immediate Supervisor
Position held at departure
Dates Employed
Position Duties
Reason for leaving
Previous Employer
Business Phone Number
Type of Business
Immediate Supervisor
Position held at departure
Dates Employed
Position Duties
Reason for leaving
Use this space to list any relevant certifications that you have
Reference
Reference
Reference
Reference Phone Number
Reference Phone Number
Reference Phone Number
Relationship to Reference
Relationship to Reference
Relationship to Reference
Drivers License Number
State Issued
Date of Expiration
Date of Birth
Use this space to list any moving violations you have within the past 10 years
I have completed an EVOC course
Yes
No
I am a Paramedic who is PIFT Certified
Yes
No
I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment Casco Bay Ambulance Service, Inc. I understand that all information on this application is subject to verification, and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize the Casco Bay Ambulance Service, Inc. to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to governmental agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee. I understand that Casco Bay Ambulance Service, Inc. is an at will employer and that my employment, should I be hired is on an at will basis.
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