Medical CredentialsPlease specify all credentials that you presently hold, if any. You will be required to provide copies of the credentials at the time of your interview.
Please include the title, issuing authority, and expiration for each.
Personal ReferencesProvide four references, not related by blood or marriage, who have known you for five years or longer. No more than two references may be current members or employees of Spring Hill EMS.
Supplemental StatementI declare, subject to the penalties of perjury, that the statements made in this application (including any statements made in any accompanying attachments) have been examined by me, and to the best of knowledge are true and correct. Furthermore, I acknowledge the obligation on my part, if accepted for membership in the Spring Hill Community Ambulance Corps (henceforth ‘the Corps’), to obey the rules and regulations of the Corps and submit to the authority of the elected officers of the Corps. In connection with the application, I authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies, military services, financial institutions, doctors, hospitals, and employers, to release any and all information that they may have about me to any officer of the Corps as permitted by law, and release them from any responsibility or liability for doing so. Furthermore, I authorize the Corps to procure an investigative report about me. I understand that such report may contain information about my background, character, and personal reputation.
Consumer Report Disclosure and ReleaseAs part of the employment or membership process, Spring Hill Community Ambulance Corps, Inc. (“the Corps”), will obtain a consumer report, which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living.
During the application process and at any time during the tenure of my employment or membership with the Corps, I hereby authorize ChoicePoint Workplace Solutions, Inc., on behalf of the Corps, to procure a consumer report, which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living. This report may be
compiled with information from courts’ record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such
investigation includes information bearing on my character, general reputation, personal characteristics, or mode of living.
Motor Vehicle Report DisclosureIn connection with my application for employment (including contract for services) or membership with Spring Hill Community Ambulance Corps: I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license
suspensions, and license revocations. I authorize without reservation, any party or agency contacted to furnish the above-mentioned information. I have the right to obtain information as to the name, address, and phone number of any agency providing such information. Furthermore, I may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information as well as the recipients of any reports on me which that agency has previously furnished within the two (2) year period preceding my request. This authorization shall remain on file and shall serve as ongoing authorization for Spring Hill Community Ambulance Corps to procure Motor Vehicle Reports at any time during my employment, membership, or contract period.
Parental ConsentI am the parent (or guardian) of the applicant named above. I am aware that the applicant is
applying for membership with Spring Hill Community Ambulance Corps, Inc. (“Spring Hill”). I am familiar with the mission, rules, regulations, and requirements of Spring Hill. I understand that consumer reports, which may contain public record information, may be requested and obtained. These reports may include information about the applicant’s previous driving record, including court actions, citations, license suspensions, and license revocations. I understand that a consumer report may be requested and obtained, which may contain information regarding the applicant’s character, general reputation, personal characteristics, or mode of living. I hereby authorize ChoicePoint Workplace Solutions, Inc., on behalf of Spring Hill, to procure such information in regard to the applicant. I give permission for the applicant to participate in activities with Spring Hill. I also give permission for Spring Hill to treat the applicant if injury or illness should occur. I agree, on behalf of the applicant, to release, indemnify, and hold harmless Spring Hill Community Ambulance Corps, Inc. and its officers, members, employees or other agents, and the medical control physician and medical control facility, from any and all claims, actions, causes of action, damages, or legal liability of any kind resulting from my decision, or from any act or omission of Spring Hill, or its officers or members, or from the medical control physician and medical control facility, except as specifically provided for by agency regulation. I understand that this release will be governed by the laws of the State of New York.