Employment Application

Armstrong Ambulance does not discriminate in hiring or employment on the basis of race, color, religion, national origin, sex, ancestry, sexual orientation, age, handicap, or any other characteristic protected by Federal, State or Local law. No question on this application is intended to secure information to be used for such discrimination. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment.

I recognize that any offer of employment will be conditional upon my showing documents establishing that I am authorized to be employed by Armstrong Ambulance and I agree to provide such documents as required by law.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed.

In processing this employment application, we may request that a consumer report be prepared which may include information as to your character, general reputation, police record, CORI check, personal characteristics, and mode of living. You have the right to request that Armstrong completely and accurately disclose to you the nature and scope of the investigation requested. Such a request must be made in writing to the Human Resources Department within a reasonable time after you complete this application.

Armstrong Ambulance is authorized to obtain pertinent reference information from former employers in the processing of this application.

By submitting this form, you acknowledge that you have read and understand the foregoing disclosures.

Fields with an asterisk (*) are required.


List previous addresses within the US, except Military, if it has changed during the past 5 years:

Are you over the age of 18? (Proof of identity and eligibility will be required upon employment) *

Only U.S. Citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? *


Can you perform the essential functions of the position for which you are applying?

If you have questions as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer this question.

What type of position are you interested in?


Days and hours available

If employed by Armstrong, you will notify your supervisor in writing should your availability change.

  Mon Tue Wed Thu Fri Sat Sun
From
To

Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything that would interfere with your regular attendance and punctuality if you were offered a job with our company?


Have you been employed here previously?

Have you ever applied here before?

You may wish to include civic and community activities, professional societies in which you participate, hobbies, sports, special training or skills such as typing, word processing, accounting, and the like.


Education

Type Name & address Major subject Last year attended Graduated
High school
College
Grad. school
Bus. or trade school

If applicable, how many years of experience do you have with the following?

What EMT and/or Paramedic Program did you attend?

Have you completed any special courses, seminars, or training that would enable you to perform the position for which you are applying?

Omit any which reflect your race, color, religion, age, sex, sexual orientation, marital status, or disabilities.

Are you planning to pursue further studies?


Employment Record

Starting with present or most recent, list all previous employers or verifiable volunteer work. List only employers located within the United States. Include self-employment, summer, and part-time jobs.

Company #1 (most recent)

May we contact them?

Company #2

May we contact them?

Company #3

May we contact them?

If you are now employed, may we contact your present employer?


Notification and Agreement

Please read before submitting this application.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION, OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to the employment interviewer before submitting. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

I authorize the investigation of all statements and information contained in this application. I understand that a pre-employment drug screening test will be performed. I release from all liability anyone supplying such information and I also release the employer from all liability that may result from making an investigation.

If hired, I agree to abide by all of the company rules and regulations. I understand that if employed, my employment may be terminated with or without cause and with or without notice at any time at the option of either Armstrong Ambulance or me. I further understand that no representation, whether or oral or written, by any representative of agent of Armstrong Ambulance, at any time, can constitute a contract of employment. I further understand that the at-will nature of my employment cannot be changed except by a formal written contract signed by an executive of Armstrong Ambulance.

I understand that Armstrong Ambulance and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits, or other terms or conditions of employment.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied by me on this application and in any accompanying documents. Without limiting in any way the at-will status of my employment if I am hired, I understand that if any of the statements on this application and its accompanying documents are untrue, I may be immediately discharged.

By checking below you agree to the above *


You are invited to provide furthur information to assist Armstrong Ambulance Service in meeting government reporting requirements and furthering its affirmative action efforts in the employment and advancement of qualified minorities and women. Providing this information is strictly voluntary and any information you provide will be kept confidential and will not be used as the basis for any adverse employment decision.

Race/ethnic designation
Gender
Race/ethnic definitions
  • White (Not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East
  • Black/African American (Not of Hispanic origin): All persons having origins in any of the Black racial groups of Africa.
  • Hispanic or Latino: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultural origin, regardless of race.
  • Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This area includes, for example, China, India, Japan, and Korea.
  • Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of the Hawaiian Islands or other Pacific Islands, including the Philippine Islands and Samoa.
  • American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains cultural identification through tribal affiliation or community recognition.

Armstrong Ambulance Service is an Equal Opportunity / Affirmative Action Employer

Invitation to Self Identify

Armstrong Ambulance Service is a Government Contractor subject to the requirements of Section 503 of the Rehabilitation Act of 1973, as amended, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended (38 U.S.C. 4212). Section 503 prohibits discrimination in employment on the basis of disability, and requires affirmative action to employ, and to advance in employment, qualified individuals with disabilities. 38 U.S.C. 4212 prohibits discrimination in employment on the basis of special disabled, Vietnam era, recently separated veteran, or other protected veteran status, and requires affirmative action to employ, and to advance in employment, qualified covered veterans.

Armstrong Ambulance Service has affirmative action programs which describe its efforts to employ, and advance in employment, qualified persons with disabilities and qualified covered veterans. If you are an individual with a disability, a special disabled veteran, Vietnam era veteran, recently separated veteran, or other protected veteran, and would like to be considered under the affirmative action program, please tell us, either at this time or at any time in the future. This information will assist us in placing you in an appropriate position and, if you are an individual with a disability or a special disabled veteran, in making accommodations for your disability.

Providing this information is strictly voluntary. Any information you provide will be kept confidential and will not be used in a manner inconsistent with the law. Furthermore, refusal to provide this information will not subject you to any adverse treatment.

Veteran status (please check all that apply)

Do you have a physical or mental disability which would limit your ability to perform the essential functions of the position for which you are applying?

If there are any accommodations which we could make which would enable you to perform the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of certain duties relating to the job, provision of personal assistance services, or other accommodations, please describe them.

Definitions
  • Special disabled veteran means (1) a veteran who is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by Department of Veterans Affairs for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment handicap; or (2) a person who was discharged or released from active duty because of a service-connected disability
  • Individual with a disability means any person who:
    • has a physical or mental impairment which substantially limits one or more of such person’s major life activities;
    • has a record of such impairment; or
    • is regarded as having such impairment
  • Qualified special disabled veteran means a special disabled veteran who satisfies the requisite skill, experience, education and other job-related requirements of the employment position such veteran holds or desires, and who, with or without reasonable accommodation, can perform the essential functions of such position.
  • Qualified individual with a disability means an individual with a disability who satisfies requisite skill, experience, education and other job-related requirements of a particular job and is capable of performing its essential functions with or without reasonable accommodation to his/her disability.
  • Substantially Limits means that the disabled individual is significantly restricted in the ability to perform a class or broad range of jobs compared to the average person with comparable training, skills, and abilities.
  • Vietnam-era veteran means a person who served more than 180 days of active military, naval or air service, any part of which occurred (1) in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (2) during the period between August 5, 1964 and May 7, 1975 otherwise, and who was (1) discharged or released with other than a dishonorable discharge or (2) was discharged or released from active duty because of a service-connected disability.
  • Other Protected Veteran means a person who served on active duty at any point between December 7, 1941 and April 28, 1952; or in a campaign or expedition for which a campaign badge has been authorized, under laws administered by the Department of Defense.
  • Recently Separated Veteran means any veteran during the one-year period beginning on the date of such veteran’s discharge or release from active duty.