Employment

Employment Application

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you employment that

Name *

First

Last

Address (Street Address, Town/City, State) *

Phone Number *

Email *

Certification Level *

MA EMT/Paramedic Certification Number *

NREMT Certification Number *

Do you have a valid driver's license & reliable transportation? *

Please list any additional EMS certifications (TECC, PHTLS, AMLS, etc). Please include certification numbers and expiration dates.

How many hours are you looking for? *

Shift Availability *

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I am on a rotating schedule with another agency

Hours/shifts will be discussed during initial interview.

Preferred Shift(s) – Select all that apply *

Day Shift (08:00-16:00 or similar)
Evening Shift (16:00-00:00 or similar)
Overnight Shift (00:00-08:00 or similar)
Daytime 12hr (08:00-20:00 or similar)
Overnight 12hr (20:00-08:00 or similar)
Any/no preference

EMS experience level: *

Please describe past work experience (3 most recent preferred). Include contact information for previous/current employers if we may contact them. *

Were you referred to us? If so, please specify here. *

Have you been employed by the West Brookfield Rescue Squad in the past? If so, when? *

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize West Brookfield Rescue Squad, Inc. to contact former employers regarding my employment. I authorize my former employers to fully and freely communicate information regarding my previous employment, attendance, and professionalism. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment. *

Agree

Electronic Signature & Date *

West Brookfield Rescue Squad

Serving since 1952
30 Ware St, West Brookfield, MA 01585
(508) 637-1778