DEPUTY EMS DIRECTOR APPLICATION PACKET MADISON AMBULANCE ASSOCIATION

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D

EPUTY

EMS

D

IRECTOR

A

PPLICATION

P

ACKET

MADISON AMBULANCE ASSOCIATION

9

O

LD

R

OUTE

79

MADISON,

CONNECTICUT

ALL MATERIALS MUST BE RECEIVED (NOT POSTMARKED) by 4:00 PM 14 January 2013

Application deadline extension: 1 February 2013 by 4:00 PM

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Job Title: Deputy EMS Director Rev. Date: 20 December 2012

Department: Operations FLSA Status: Non-Exempt

Reports to: EMS Director Full Time: 40 hours / week

Preface:

The Deputy EMS Director shall be second in command within the operations section of the Madison Ambulance Association, Inc. (“MAA”). The Deputy Director shall be responsible for the following but not limited to:

• Emergency Medical Service delivery

• Personnel

• Training

• Quality Assurance

• Continuous Quality Improvement

In addition, the Deputy EMS Director shall be responsible for the coordination of organizational activities to assure smooth and consistent delivery of clinical services. The Deputy EMS Director shall provide leadership to employees, encourage professionalism and a caring approach among all providers, coach, facilitate, and lead the workforce in the consistent achievement of high quality patient care delivery and skills proficiency with consistently outstanding customer satisfaction. The Deputy EMS Director shall also be responsible for assuring the appropriate consistent use of medical protocols, incident command, safety standards, policy and standard operating guidelines with the presentation of good judgment at all times in addition to demonstrating the highest degree of professionalism and customer service. Lastly, the Deputy EMS Director will be responsible for all management activities in the EMS Director’s absence. Emergency Medical Service Delivery:

Professional and compassionate service needs to be the hallmark of the MAA. To achieve this goal the Deputy EMS Director needs to assist the EMS Director by:

• Ensuring all regional, state and federal regulatory requirements are met;

• Ensuring response times are monitored and met in accordance with Company policy;

• Reviewing standard operating procedures, guidelines and policies at least annually to ensure that all are in accordance with current regional, state and federal policies;

• Addressing citizen inquiries when appropriate;

• Working on the EMS Director’s behalf to coordinate major EMS incidents;

• Coordinating the EMS function as identified in the incident command system as utilized within the Town of Madison when appropriate;

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• Ensuring external communications are clear, timely, accurate and further the positive image of MAA;

• Maintaining and enhancing MAA’s Quality Assurance program as well as the Continuous Quality Improvement Program, and;

• Conducting quality assurance for Basic Life Support (BLS) and Advance Life Support (ALS) electronic patient care run forms.

Personnel:

To achieve the level of professional, compassionate service expected of the MAA, the Deputy EMS Director must assist EMS Director and ensure that:

• Personnel are properly certified to the level of their hired competency in accordance with local, state and national protocols and guidelines;

• Personnel maintain basic and advanced life support skills in accordance with local, state and national protocols and guidelines;

• Personnel issues are dealt with in accordance with Company policy;

• Staffing schedules are developed to ensure that all shifts are properly staffed in accordance with Company policy;

• A new-hire program is maintained that is effectively run to include advertising for positions, interviews, testing, hiring and mentoring new candidates, and;

• Assist the EMS Director documenting and conducting annual performance reviews. Essential duties and responsibilities:

The candidate must possess and apply knowledge, skills and abilities necessary to perform the duties of a Paramedic, in a dignified and compassionate manner, including:

• Responding to emergency and non-emergency calls for service calmly, efficiently and promptly;

• Administering basic life and advanced life support to patients at the scene, en route to the hospital, and in a pre-hospital setting, in accordance with federal, state, and local laws, regulations, and standards and in accordance with Company policies;

• Assessing the nature and extent of injury or illness to establish and prioritize medical procedures to be followed;

• Utilize medical equipment and procedures including defibrillator, EKG monitor, oxygen, suction devices, intravenous fluids, CPR, and other procedures and medications as required to provide advanced medical care;

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• Working jointly with the fire departments in town to assist in rescuing and extricating victims of accidents, sudden illness or entrapment using proper rescue and medical techniques (when appropriate);

• Treating patients at the scene, en route to the hospital, and in a pre-hospital setting, in accordance with federal, state, local, laws, regulations, and standards;

• Effectively communicating with professional medical personnel and treatment facilities to obtain instructions regarding further treatment and/or to arrange reception of patients to the appropriate center;

• Act as a team leader;

• Take responsibility for scene management as needed;

• Maintaining order at scenes, including crowd disbursement and control of family and friends; and

• Completing patient care forms and all other documentation in a competent and timely fashion. The candidate must perform all job responsibilities in a manner that protects patient privacy:

• The candidate is expected to protect the privacy of all patient information in accordance with Madison Ambulance’s privacy policies, procedures, and practices, as required by federal, Connecticut law and in accordance with general principles of professionalism as a health care provider. Failure to comply with the Company’s Policies and Procedures on patient privacy may result in disciplinary action up to and including termination of employment with Madison Ambulance.

• The candidate may access protected health information and other patient information only to the extent that is necessary to complete the job duties. The candidate may only share such information with those who have a need to know specific patient information you have in your possession to complete their job responsibilities related to treatment, payment or other Company operations.

• The candidate is encouraged and expected to report, without the threat of retaliation, any concerns regarding the Company’s Policies and Procedures on patient privacy and any observed practices in violation of that Policy to the designated Privacy Officer.

• The candidate is expected to actively participate in Company privacy training and is required to communicate privacy policy information to coworkers, observers, patients and others in accordance with Company Policy.

The candidate must possess and apply knowledge and skills necessary to perform the duties of a driver of ambulance equipment, including:

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• Responding to instructions from a dispatcher and driving and operating specially equipped emergency vehicles to specified locations at a safe and controlled speed, in accordance with federal, state, local law, regulations and standards;

• Assuring that vehicles are in good working condition at all times, are properly maintained and stocked, have all necessary equipment and equipment is in good working order at all times;

• Cleaning, organizing and restocking vehicles in a ready condition after each transport;

• Receiving requests for emergency and non-emergency ambulance service and other duties-related communication via two-way radio and other communication devices;

• Maintaining accurate records of ambulance equipment and other emergency equipment and/or personnel dispatched to each emergency and non-emergency request and other operation and administrative data as required to maintain the operational continuity of Madison Ambulance and as directed by superiors;

• Handling telephone communications professionally and efficiently with careful regard to the divulgence of information;

• Monitoring communication equipment to maintain contact with the dispatcher; and

• Maintaining apparatus and equipment in accordance with Company policies.

The candidate must perform routine tasks in and around the ambulance service building, including:

• Checking, restocking, inventorying and cleaning any apparatus operated by Madison Ambulance;

• Cleaning, emptying trash and other related duties in the station;

• Washing and drying towels, blankets and other laundry in the provided washing and drying equipment;

• Representing the ambulance service while on duty at public service functions, expositions, and other public events;

• Providing ambulance stand-by services at sporting events or any other activities designated by the EMS Director; and

• Performing any other duty related to Madison Ambulance as designated by the EMS Director. The candidate must also:

• Be a team player, as EMS is a team effort, and providers must provide necessary assistance to ensure system sanitation, readiness and adherence to quality assurance standards;

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• Be flexible, as emergency services operate on a 24-hour clock; the candidate’s assigned work shift schedule may vary and the candidate should be available to respond immediately for a call during the assigned work period, and the start and shift times may vary due to the nature of the business;

• This position is a non-exempt position and is subject to order-in during off duty time or time not scheduled.

• Maintain a thorough working knowledge of local geography, which includes maps and streets;

• Conduct him/herself in a courteous, helpful, dignified and professional manner at all times when dealing with patients, co-workers, supervisors and or the public.

• Maintain a thorough working knowledge of applicable current standards of care, including equipment functions and uses; and

• Assure that all certifications, licenses and registrations are maintained in accordance with Company policy.

Qualifications

Educational Requirements

The candidate must have a minimum of either a high school diploma or a GED as evidence of completion of a high school education. A Bachelor of Science or Arts degree in business, management, public administration, EMS, Fire Science, or similar degree is strongly preferred. Certificates, Licenses and Registrations

The candidate must possess and maintain the following:

• Valid Connecticut driver's license;

• Connecticut Licensed Paramedic. (National Registry preferred.) Must be able to obtain Yale New Haven Sponsor Hospital Program Medical Authorization within six (6) months of hire;

• American Heart Association Healthcare Provider;

• National Incident Management System Certifications 700, 800, 100, 200 (required);

• PALS, ACLS, PEPP, PHTLS, BTLS, and other certifications as required by Yale New Haven Sponsor Hospital Program;

• National Incident Management System Certifications 300 and 400 (preferred);

• EVOC Instructor (preferred);

• Hazardous Materials Awareness (preferred);

• American Heart Association BCLS/ACLS Provider (Instructor preferred);

• PHTLS Provider or equivalent (Instructor preferred), and;

• Connecticut EMS-I (preferred).

Minimum Experience, Abilities Required and Special Requirements

This position requires eight (8) years of active experience as a Paramedic in the field of emergency medical services or equivalent. The candidate must possess effective oral, written and interpersonal communication skills. The candidate must possess basic working knowledge of computers, word processing software, and be able to enter necessary data into a computer.

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The candidate must have demonstrated experience in EMS Supervisory position(s) or equivalent for a minimum of three (3) years.

Physical Requirements of the Position:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. The position requires significant physical strength and dexterity and the ability to function in very adverse environments with exposure to numerous safety risks typically found at emergency scenes.

The following guidelines are used to describe the frequency of activities in this position:

(Occasionally equals 1-33%; Frequently equals 34%-66%; and Continuously equals 67-100% of a typical work day.)

STANDING/WALKING: Frequently to continuously when responding to calls. Optional while at rest at the facility. This usually includes: going to and from the emergency vehicle, getting patients from their locations, and rendering treatment. Walking and running may vary, however, as the patient may be located inside a large, multi-floored facility. Standing, walking and running could be on all types of surfaces, including but not limited to: asphalt, cement, concrete, soft/packed dirt, linoleum, wood, hardwood floors, etc. The individual must be able to go up and down slight inclines or declines that may be found at roadsides, agricultural areas, etc. At a location, standing would occur more often than walking or running. Standing would occur on the wide variety of surfaces mentioned above. Standing could last from a few minutes to hours, depending on the situation. Standing could occur in the standard erect position, the kneeling or squatting position, etc.

SITTING: Frequently when responding to a location, the individual will sit in the emergency vehicle. The emergency vehicles are equipped with a standard installed vehicle seat. The time performing the sitting activity on a call would depend upon the specific situation.

LIFTING AND CARRYING: Frequently to continuously required to lift and carry weights ranging from a few pounds to over two hundred and fifty (250) pounds and above. Candidates will need to lift and carry, with one team member, adult patients, lifting them from various positions (such as a bed or a chair) onto various patient movement devices, such as an ambulance

stretcher, a stair chair, long back boards, etc., and then efficiently and safely move them into an ambulance.

BENDING AND STOOPING: Frequently throughout a work shift the individual will be required to bend in a range of 1 to 90 degrees. The average situation will require the individual to work in a range of 35 to 65 degree bends. This would involve: lifting a patient, lifting equipment, treating a patient at ground level, sitting on a bench located in the ambulance. This activity may be prolonged and last up to 30 minutes or more. During any given call, the provider may bend and/or stoop 1 to 15 times per incident.

CROUCHING AND KNEELING: Frequently. Crouching and kneeling may be performed when on the scene picking up equipment or assisting patients. The actual number of times this is done depends on the particular incident but may be up to 15 times for a duration up to 30 minutes or greater.

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CLIMBING: Occasionally. This is required when climbing steps up and down with a patient on a stretcher or other device, and when entering or exiting the emergency vehicle. Generally, the climbing would require that the candidate lifts and carries heavy objects such as a stretcher or other device with a patient on it. Balancing may be required when backing down staircases.

REACHING: Frequently to continuously throughout the work shift in order to review monitoring equipment, operate communication equipment, administer oxygen, and operate equipment. The candidate may also be required to reach in precarious positions, such as in a vehicle, which has been crushed in an accident, or in other confined spaces. If working inside the ambulance en route to a medical facility, the candidate will need to reach to access the patient and supplies. Reaching will involve partial to full extension of the arms.

PUSHING AND PULLING: Frequently. The activities that would require the most force in pushing and pulling is when removing or returning a gurney to the emergency vehicle, with and without a patient on the gurney. The weight required to push/pull will vary, depending on the weight on the gurney. Slight pushing will be required if the candidate is performing CPR, which can require repetitive pushing and may range from a few minutes to hours. Pushing and pulling is required when operating and closing vehicle doors.

HANDLING OR GRASPING: Continuously. While working at any given location, continual bilateral gross manipulation is performed in this position. This may be involved when:

opening/closing doors; and using, handling, carrying and/or operating medical equipment boxes that may weigh approximately fifty (50) pounds or more, stretcher rails, various handles

attached to equipment, and tools. The arm and hand must be able to perform al types of positions, including supination and pronation. Hyperextension, extension and flexion of the fingers will be involved, ulnar and radial deviation, abduction and adduction of the hand and wrist will be required. A wide variety of grasping will be required, such as cylindrical grasping, palmer grasping, hook grasping, tip grasping, lateral grasping and spherical grasping.

HAZARDS:

The candidate, when responding to emergencies, can be exposed to dust, fumes, gases, fire, smoke, adverse weather conditions, and chemicals. Driving at speeds beyond the posted limit with due regard may occur and, therefore, the candidate may be exposed to vehicular accidents at a higher speed than normal. There is also exposure to body substances that may contain infectious materials that could cause illness or death. There is potential for bodily harm or death from violent patients, bystanders, or other dangers.

OTHER PHYSICAL REQUIREMENTS

• Maintain balance and strength in awkward positions; • Speak clearly under stressful circumstances;

• Accurately communicate ideas orally and in writing in English; • Respond physically with speed;

• Speak loudly, and;

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Page 9 of 20 Mental Requirements of the Position

• Handle a significant number of stressful situations, and be able to function calmly; coolly and collectedly under all types of stressful situations;

• Get along well with diverse personalities;

• Communicate with patients and others with empathy and respect;

• Create and maintain a positive and cooperative working environment in stressful situations;

• Work smoothly and professionally in an environment where teamwork is essential;

• Analyze and interpret difficult and complex patient care and personnel situations;

• Work independently with a minimal supervision for assigned tasks;

• Reading (simple and complex), writing (complex), memorization, analyzing, math skills (simple);

• Exercise sound independent judgment within general Policy and procedural guidelines;

• Anticipate and identify problems and take initiative to prevent or correct them;

• Establish and maintain effective working relationships with all levels of personnel within the medical community, Madison Ambulance, outside agencies, patients, and members of the community;

• Understand and follow federal, state and local laws, and Madison Ambulance policies, procedures, and rules;

• Follow orders;

• Remember and apply concepts, knowledge and principles; and

• Appropriate deal with stress and maintain composure when encountering serious injuries or illnesses.

Equipment Used

• Occasionally: Wheelchair, Stair chair, medications, monitor/defibrillator, suction equipment, airway equipment, Lucas Device, telephone, vacuum cleaner, cleaning equipment, protective devices, protective clothing

• Frequently: IV supplies, bandaging, disposable supplies, durable equipment

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DISCLAIMER

The information provided in this description is designed to indicate the general nature and level of work performed by candidates within this position. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, qualifications and working conditions required of employees assigned to this position. Management has the sole discretion to add or modify the duties of the position and to designate other functions at any time. This position description is not an employment agreement or contract.

ACKNOWLEDGMENT

I, ___________________________, have read this position description in its entirety and fully

understand the expectations, requirements and hazards associated with this position, and that the job description and duties are subject to change at the discretion of the Company. I also understand that if employed by the Company, I am employed as an at-will employee and that the Company or I may terminate the employment relationship at any time, without notice, and for any lawful reasons.

_________________________________________ Candidate Name (please print)

________________________________ ___________________

Signature of Candidate Date

________________________________ ___________________

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Page 11 of 20 THE INSTRUCTIONS SHOULD BE REVIEWED CAREFULLY BY THE CANDIDATE AND COMPLETED PACKETS

SHOULD BE RETURNED TO THE EMS DIRECTOR – MADISON AMBULANCE ASSOCIATION, INC. INSTRUCTIONS

1. Read each question in the Application carefully. Candidates are required to answer every question. If a question does not apply to you, please mark N/A (not applicable).

2. All entries, except your signature, must be printed legibly in blue or black ink, or be typed. If you cannot complete a question in the space provided, use a separate sheet and attach it to the application and indicate additional information is attached.

3. All applications must be returned to:

Madison Ambulance Association, Inc. Attn: EMS Director

9 Old Route 79 Madison, CT 06443

4. All applications must be received by 4:00 P.M. on, or before 14 January 2013.

Application

deadline extension: 1 February 2013 by 4:00 PM.

5. All applicants are required to properly complete all forms involved in the application and testing process. Applicants are reminded to have notarized all applicable pages prior to returning the application. A Notary Public is a person who is legally authorized to witness and certify documents. Documents can usually be certified at a Town or City Clerk’s administrative office. 6. All applications must be submitted in person or received by a mailing or delivery service by the

due date and time. No applications will be accepted via fax machine, email or at locations other than the places indicated.

7. Incomplete packages will be disqualified.

8. The Madison Ambulance Association’s requirements for employment are as follows: a. Must be a citizen of the United States.

b. Must be a minimum of 21 years of age. (on date applications are due)

c. Must have and maintain State of CT Paramedic license for duration of employment and YaleNew Haven Sponsor Hospital Program medical authorization for duration of employment.

d. Out of state National Registry certified Paramedics may apply with the requirement that they gain a state of Connecticut Paramedic license within the first six months of

employment and obtain Yale New Haven Sponsor Hospital medical authorization within the three (3) months of obtaining a Connecticut Paramedic License.

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e. CT Licensed Paramedics who are not currently medically authorized by Yale New Haven Sponsor Hospital will be required to attain medical authorization within six (6) months of employment.

f. Be in general good health and have sufficient strength, stamina and agility to perform the duties required by the position.

g. Must pass a background and credit check, drug testing, physical examination, lift test and an interview by the Madison Ambulance Association Board of Directors and Interview Committee.

h. Have no criminal record and possess excellent moral character.

i. Have graduated High School (required) and completed a college program with a bachelor’s degree (preferred).

j. Have normal hearing, normal color vision and depth perception, with no marked muscle imbalance.

k. Visual acuity 20/20 to 20/40, corrected to 20/20.

l. Have a Connecticut motor vehicle operator’s license at the time of appointment. 9. Regarding Criminal Record: Have no criminal record revealing the conviction of a felony under

state or federal law; have no criminal record revealing the conviction of a Class A or Class B misdemeanor under State of Connecticut law or of a crime in any other jurisdiction that, if committed in this state, would constitute a Class A or Class B misdemeanor; or have no criminal record revealing a conviction of perjury or false statement.

10. Undergo a criminal record check by name and date of birth. Said record check will be made in Connecticut and any other state in which the applicant has lived.

11. Undergo a background investigation, including a check of motor vehicle law convictions for operating a motor vehicle under the influence of intoxicating beverages or narcotics or controlled substance or for evasion of responsibility.

12. Upon a preliminary job offer, undergo a controlled substance /alcohol screen. That the result of such screen indicates no presence of any controlled substance, not prescribed by a licensed physician for the candidate.

13. Candidates will be subject to other screening phases, including a comprehensive medical examination and credit check. The examinations will be conducted in accordance with applicable law.

14. Candidates must file with their application, clean and legible copies of any certifications, licenses, (including a valid driver’s license) and diplomas.

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Page 13 of 20 Madison Ambulance Association, Inc. – Madison, CT.

Application for Employment – Deputy EMS Director

1. Name _______________________________________________________________________________

Last First Middle

2. Present Address_______________________________________________________________________

Street City State Zip

3. Telephone (____) ___________(C) ____________________ E-Mail: ______________________________ Social Security # _____ - ____ -______

PERSONAL HISTORY 4. Are you a U. S. Citizen? Yes ______ No ______

5. List any other names, nicknames, or aliases that you may have been known by:

_____________________________________________________________________________________________

6. List chronologically all of your residences for the past ten years (beginning with your current address and working backward):

From (MM/YEAR) To (MM/YEAR) Street City State Zip

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 7. Education

Name & Location of School Did you Degree Total Major/ Dates Graduate Received Credits Minor Attended High School _______________ ________ ________ ________ ________ ________ City/State _______________ College/ _______________ ________ ________ ________ ________ ________ University City/State _______________ College/ _______________ ________ ________ ________ ________ ________ University City/State _______________

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Other _______________ ________ ________ ________ ________ ________ School

City/State _______________

8. Employment - Starting with present or most recent employment and working backward, consecutively list all employment.

Dates of Employment: ______________ to ____________

Company Name and Address:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ Position Held (Description): _______________________________________________________________________ Name and Title of Supervisor: _____________________________________________________________________ Reason for Leaving: _______________________________________________________________________

Dates of Employment: ______________ to ____________

Company Name and Address:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ Position Held (Description): _______________________________________________________________________ Name and Title of Supervisor: _____________________________________________________________________ Reason for Leaving: _______________________________________________________________________

Dates of Employment: ______________ to ____________

Company Name and Address:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ Position Held (Description): _______________________________________________________________________ Name and Title of Supervisor: _____________________________________________________________________ Reason for Leaving: _______________________________________________________________________

Dates of Employment: ______________ to ____________

Company Name and Address:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ Position Held (Description): _______________________________________________________________________ Name and Title of Supervisor: _____________________________________________________________________

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Reason for Leaving: _______________________________________________________________________ Dates of Employment: ______________ to ____________

9. Military

Have you ever served in any military organization of the United States? Yes ______ No ______ Dates of Service ___________ to __________

Branch _____________________ Highest Rank Held ____________________ Special Duties/Training: _____________________________________________ ________________________________________________________________ ________________________________________________________________ Discharge Type_____________________ Status _____________________ Are you now a member of the Reserve or National Guard?

Yes ______ No ______ Were you in the Past? Yes _____ No _____ Branch ____________________ Rank ____________________________ Address _________________________________________________________ Dates _____________ to _______________

10. References

Give the names of three references (not relatives or former employers) who have known you well during the past three years).

1. Name: _________________________ Telephone: _________________________

Address_______________________________________________________________________________________

Street City State Zip

Occupation: _______________________________ Years Known: _________________

Business Address: _________________________ Telephone: _________________________

2. Name: _________________________ Telephone: _________________________

Address_______________________________________________________________________________________

Street City State Zip

Occupation: _______________________________ Years Known: _________________

Business Address: _________________________ Telephone: _________________________

3. Name: _________________________ Telephone: _________________________

Address_______________________________________________________________________________________

Street City State Zip

Occupation: _______________________________ Years Known: _________________

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11. Criminal

Have you ever been convicted of any crime or violation? Yes ____ No ____

If yes, provide details including date(s) of arrest(s) and hearings(s), location of offense(s), charge(s), details of the incident(s) and disposition:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Except as provided by State of Connecticut provisions and federal law, the existence of a police record does not automatically disqualify an applicant from employment.

12. Are you a licensed automobile operator? Yes ______ No ______

State operator number and classification _______________________________

13. Have you ever been convicted of a motor vehicle offense?

Yes _____ No _____ if yes, list the offense(s), date(s), disposition(s) and location(s). Offense Date Disposition Location

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

14. Has your operator’s license ever been revoked or suspended?

Yes _____ No _____ if yes, please explain:

_____________________________________________________________________________________________ _____________________________________________________________________________________________

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GENERAL

15. Are you presently using, ingesting, injecting, sniffing, absorbing or otherwise using any nonprescription drugs or substances including hallucinogenic drugs, stimulants, depressants, and narcotic drugs, other types of chemicals or alcohol?

Yes ____ No ____ if yes, please answer the following:

When was the last time you used a drug or substance? ________________________________________________ _____________________________________________________________________________________________ Which drug(s) or substance(s) did you use? __________________________________________________________ _____________________________________________________________________________________________

16. List any special skills, qualifications and licenses you possess (do not include motor vehicle operator’s license or Paramedic license): _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

17. Paramedic License #: _____________________ and Expiration Date: ______________________ (attach copy) 18. Driver’s License #: _____________________ Expiration Date: ______________________ (attach copy) 19. Birth Certificate (attach copy)

20. High School Diploma or GED (attach copy) 21. College diploma (attach copy)

22. Social Security Card (attach copy)

I hereby swear that all answers on this application are true. Dated at _____________________, on this the _________ day of________.

__________________________________ Signature of Applicant

Subscribed to and sworn to before me at _____________ on this the ________day of _________. ____________________________

Notary Public SEAL

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CERTIFICATION AND AGREEMENTS

I understand that a positive and properly confirmed drug test for controlled substances or refusal to submit to a drug test is grounds for denial or termination of employment. I authorize representatives from the Madison Ambulance Association, Inc. to obtain pertinent information from my previous employers, references, and other persons with knowledge of my work history and background. I authorize my previous employers, references, and persons with knowledge of my work history and background to provide pertinent information to the Madison Ambulance Association, Inc. of Madison, CT and hereby release all such persons and waive any and all claims, demands, or causes of action whatsoever, in connection with the request for and release of such information. I certify that the information on this job application is true and complete to the best of my knowledge. I understand that any willful omissions or falsification will be reason for withdrawal of a job offer or termination of employment whenever the omission or falsehood is discovered. I authorize any investigation into the statements I have made in this application as necessary to arrive at any employment decision. I understand that nothing stated by the Madison Ambulance Association, Inc., in writing or orally, during the interview and/or hiring process is to be construed as creating a contract between the applicant and the Madison Ambulance Association, Inc..

I have read, understand and agree to the foregoing.

__________________________

Signature of Applicant

__________________________ Print Name

Subscribed to and sworn to before me at _____________ on this the ________day of _________. ____________________________

Notary Public SEAL

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MADISON AMBULANCE ASSOCIATION, INC. AGREEMENT

I hereby authorize representatives of the Madison Ambulance Association, Inc. of Madison, CT to obtain a consumer credit report, including an investigative consumer report, as part of my application for employment.

I have read, understand and agree to the foregoing.

__________________________

Signature of Applicant

__________________________ Print Name

Subscribed to and sworn to before me at _____________ on this the ________day of _________. ____________________________

Notary Public SEAL

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BACKGROUND INVESTIGATION CONSENT FORM MADISON AMBULANCE ASSOCIATION, Inc.

Thank you for your interest in employment at Madison Ambulance Association. As part of the employment process, certain information may be requested as it relates to the employment you seek. Your signature on this document indicates that you have read and understand the conditions set forth by Madison Ambulance Association.

* * * * * * * *

I understand Madison Ambulance Association may perform a pre-employment background investigation to determine my suitability for the employment I seek; I hereby authorize Madison Ambulance Association to secure the information necessary to make such a decision. I further understand that while an offer of employment might precede any such investigation, actual employment is contingent upon a determination of my suitability for the employment I seek.

I certify that if I am offered a position I will provide Madison Ambulance Association acceptable documents on my first day of employment that show that I am legally permitted to work in the United States.

By signing this document, I authorize Madison Ambulance Association to conduct a background investigation. I also certify that the information provided in my resume and/or letter of employment is accurate, and, if offered employment, I understand that any information falsely provided will be sufficient grounds for the immediate termination of my employment.

I hereby authorize the release of the information related to this investigation, and further release from liability any and all individuals and organizations who provide information to Madison Ambulance Association concerning my professional competence, ethics, character, criminal record (if any), and qualifications and authorize my prior employers to release any such requested information about my employment.

______________________________ ___________________________ Signature Date

Subscribed to and sworn to before me at __________ on this the ____ day of _______. SEAL __________________________ (Required) Notary Public

Please note: You will not be considered for employment if you do not provide the authorization for Madison Ambulance Association to conduct the background investigation identified above. Date of birth and Social Security number will be used onlyto complete the background investigation and will not become part of the selection process.

________________________________________ _____________________________ Name Name (maiden/alias)

________________________________________ _____________________________ Date of Birth Social Security Number

Last three states of residence:

1) ________________ _________ ________ ________ ________to__________

Address City State Zip Dates of Residence

2) ________________ _________ ________ ________ ________to__________

Address City State Zip Dates of Residence

3) ________________ _________ ________ ________ ________to__________

Address City State Zip Dates of Residence

(Federal Law prohibits discrimination against persons age 40 and over. Date of birth is used for verification purposes only and is not released to the hiring official or search committee prior to an individual’s acceptance of employment)

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