Fillable Volunteer Form Volunteer-form EVEMS App 02 (Town of Easton, Connecticut, USA)

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Volunteer Form Volunteer-form EVEMS App 02 (Town of Easton, Connecticut, USA)

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U.S.A. forms for Town of Easton, Connecticut, USA

BROWSE TOWN OF EASTON, CONNECTICUT, USA (CT) FORMS

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REFERENCES
(Please provide 3 individuals, other than family members, whom we may contact for personal references)
CPR
American Heart Association, Expiration:
American Red Cross, Expiration:
THE
EASTON VOLUNTEER
EMERGENCY MEDICAL SERVICE, INC.
P.O. BOX 62 • EASTON, CONNECTICUT 06612 • 203.452.9595 • www.eastonems.com
NAME: (First, MI, Last)
ADDRESS:
HOME PHONE:
APT: CITY: STATE: ZIPCODE:
MONTH DAY YEAR
D.O.B. SOCIAL SECURITY NUMBER:CELL PHONE: OTHER PHONE:
STATE:DRIVER LICENSE #: ARE YOU A U.S. CITIZEN? IF NO, WHAT IS YOUR COUNTRY OF CITIZENSHIP?E-MAIL ADDRESS:
Yes No
EDUCATION
NAME OF HIGH SCHOOL:
ADDRESS:
CITY:
DID YOU GRADUATE?
YEAR OF GRADUATION:
Yes No
CITY:
NAME OF COLLEGE:
ADDRESS:
STATE: ZIPCODE:
STATE: ZIPCODE:
DID YOU GRADUATE?
YEAR OF GRADUATION:
Yes No
MAJOR:
NAME OF EMPLOYER:
ADDRESS:
CITY:
PHONE:
LENGTH OF EMPLOYMENT:STATE: ZIPCODE:
EMPLOYMENT
SCHEDULING & AVAILABILITY
6PM to Midnight Midnight to 6AM 6PM to 6AMWeekdays Weekdays
WHAT TYPE OF POSITION ARE YOU APPLYING FOR?
Emergency Medical Technician Medical Response Technician Driver
PREVIOUS MEDICAL TRAINING
(Please provide copies)
MRT
Certificate Number:
Expiration Date:
EMT
Certificate Number:
Expiration Date:
Advanced Life Support: Yes No If yes, types:
Certification Number: Expiration Date: State of Certification:
PERSONAL INFORMATION
Page 1 of 4
NAME:
ADDRESS:
APT: CITY: STATE: ZIPCODE:
PHONE:
1
2
3
NAME:
ADDRESS:
APT: CITY: STATE: ZIPCODE:
PHONE:
NAME:
ADDRESS:
APT: CITY: STATE: ZIPCODE:
PHONE:
Have you been involved in any automobile accidents in the last two years? Yes No
If yes, explain:
BACKGROUND
Have you ever been convicted of a crime other than minor traffic violations in this state or elsewhere? Yes No
If yes, explain:
Do you take any prescribed drugs or medications regularly? Yes No
If yes, what type of drug is taken?
For what purpose?
Do you have any medical problems that would limit your ability to perform as an EMT or Driver? Yes No
If yes, explain:
Why do you want to join the Easton Volunteer Emergency Medical Service?
I certify that all of the above is true to the best of my knowledge.
Signature of Applicant Date
Received by Date
Page 2 of 4
DO NOT WRITE BELOW THIS LINE
Page 4 of 4
HOLD HARMLESS AGREEMENT
I, (print name) _________________________________________ hereby authorize the Town of Easton to inquire of any and all
previous employers, public or governmental officials or agencies, law enforcement agencies, or any other persons regarding
my experience, reputation, character, ability, and qualifications for membership to the Easton Volunteer Emergency Medical
Service as an Emergency Medical Technician, Medical Response Technician, or Driver. I agree to hold harmless with respect
to any information they may give, hereby releasing them from any liability to me arising therefrom.
I certify that the foregoing answers are true, correct, and complete to the best of my knowledge and belief.
I understand that false answers and or statements or omissions made on this application shall be considered sufficient
cause for dismissal from the Easton Volunteer Emergency Medical Service.
THE
EASTON VOLUNTEER
EMERGENCY MEDICAL SERVICE, INC.
P.O. BOX 62 • EASTON, CONNECTICUT 06612 • 203.452.9595 • www.eastonems.com
Signature of Applicant Date
Signature of Witness Date
Medical Certification
Name Date of Physical ____________
DOB
Address
Height __________________ Blood Pressure _________________
Weight __________________ Pulse ________________
Allergies
Medications
Date of Last Tetnus _________________
Hepatitis B Vaccine 1st _________ 2nd _________ 3rd _________
I certify that the above indivdual is physically able to work at Easton Volunteer Emergency Medical Service
Yes __________ No _________
Physician Signature __________________________________ Date __________
V0611
BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM
In the interest of maintaining the safety and security of our customers, employees and property, Easton Volunteer Emergency Medical
Service (the “Company”) will order a “consumer report” (a background report) on you in connection with your volunteer application, and if
you are accepted as a volunteer, or if you already volunteer for the Company, may order additional background reports on you for
volunteer purposes.
The background check company, ADP Screening and Selection Services, will prepare the background report for the Company. ADP
Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached at 800-367-5933.
The background report may contain information concerning your character, general reputation, personal characteristics, mode of living,
and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification;
criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and
certification checks; credit reports; and drug testing results. The information may be obtained from private and public record sources,
including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report
that includes information from such personal interviews, except in California where that term means any background report.) The nature
and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history
conducted by ADP Screening and Selection Services or another outside organization.
You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at
203 452 9595. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.
STATE SPECIFIC NOTICES
If you live or volunteer for the Company in the states listed below, please note the following:
CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon submitting proper
identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by mail. You may also ask
for a file-summary by telephone. ADP Screening and Selection Services can answer questions about information in your file, including any coded
information. If you come in person, another person can come with you, so long as that person can show proper identification.
MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may request the name,
address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this information within 5 business days of our
receipt of your request. You have the right to ask ADP Screening and Selection Services for a free copy of the report.
MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft
or other dishonest behavior in the job for which you are being considered.
MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative
consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by contacting ADP Screening and
Selection Services.
MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and
scope of the consumer report or investigative consumer report ordered, if any.
NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative
consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP Screening and Selection
Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. A copy of Article 23A of the New
York Correction Law is being provided with this form.
OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or
other dishonest behavior in the job for which you are being considered.
WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the
nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask ADP Screening and Selection Services for a
written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your credit worthiness,
credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job
for which you are being considered.
V0611
AUTHORIZATION FOR BACKGROUND CHECKS
After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my
background report, including investigative consumer reports. I understand that the Company may rely on this authorization
to order additional background reports, including investigative consumer reports, during my time as a volunteer without
asking me for my authorization again as allowed by law.
I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all
information about or concerning me, including but not limited to: my past or present employers; learning institutions,
including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local
courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector
repositories of information; and any other person, organization, or agency with any information about or concerning me.
The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited
to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal
history, military service, professional credentials and licenses and substance abuse testing.
I agree the Company may rely on this authorization to order background reports, including investigative consumer reports,
from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed
by law. I also agree that a copy of this form is valid like the signed original. I certify that all of my personal information on
this form is true and correct and understand that dishonesty will disqualify me from consideration as a volunteer with the
Company, or if I am hired or already volunteer for the Company, that my service as a volunteer may be terminated.
Last Name __________________________________ First ________________________ Middle ____________________
Maiden/Other Names _______________________________________________ Years Used _______________________
Social Security Number _______________________________________________________________________________
Driver’s License Number ________________________________________________ State _________________________
FOR IDENTIFICATION PURPOSES ONLY: Date of Birth ____/____/____ (Month/Day/Year)
Addresses Within The Past Seven Years (use a separate sheet as needed)
Present Street Address _______________________________________________________________________________
City/State/ZIP _______________________________________________________________________________________
Prior Street Address __________________________________________________________________________________
From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)
City/State/ZIP _______________________________________________________________________________________
______________________________________________________________ _____/_______/________
Signature Date: (Month/Day/Year)
If you live or volunteer for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free
copy of your background check report:
Page 2 of 3
V0611
NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES
Section 750. Definitions.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
753. Factors to be considered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employment.
755. Enforcement.
§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to
perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or
instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however,
that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle,
shotgun, or other firearm.
(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that
"employment" shall not, for the purposes of this article, include membership in any law enforcement agency.
§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer,
who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any
person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except
where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from
disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional
misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.
§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or
employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely
by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when
such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the
individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to
the safety or welfare of specific individuals or the general public.
§753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the
following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of
one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held
by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness
or ability to perform one or more such duties or responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals
or the general public.
2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give
consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a
presumption of rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has
been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a
written statement setting forth the reasons for such denial.
§755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight
of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers
and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.
Page 3 of 3
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Volunteer Form Volunteer-form EVEMS App 02 (Town of Easton, Connecticut, USA)

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Completed 15 July 2020

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