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Application

personal information
Name *
Name
Address *
Address
Phone *
Phone
Position(s) applied for: *
Requested employment status: *
Requested employment schedule: *
EMS Credential Information
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Employment History
Address
Address
Phone Number
Phone Number
Start Date
Start Date
End Date
End Date
$
Previous Employer
Address
Address
Phone
Phone
Start Date
Start Date
End Date
End Date
$
references
reference one
Phone *
Phone
Reference Two
Phone *
Phone
terms and conditions
I hereby authorize MedCare to contact, obtain and verify the accuracy of the information contained in this employment application from all previous employers, educational institutions and references. I also hereby release from liability MedCare and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for the cancellation of this application or immediate termination of my employment when it has been or is discovered. If I become an MedCare employee, I acknowledge that there is no specific length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, I acknowledge and understand that either I or MedCare can terminate the relationship at will, with or without cause at any time so long there is no violation of applicable federal and/or state law(s). I understand that it is the policy of MedCare not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the American Disabilities Act (ADA). I also understand that if I become employed, it is my responsibility to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing and that I seek employment under these conditions.
Signature
I represent that I have fully understood the following questions, that my answers are truthful and accurate, and that the omission of any material fact, commission of any false statement, and/or any attempt to misrepresent the truth will result in immediate termination. I further understand that knowingly making an omission of a material fact or a false statement is in violation of 105 CMR 170940: Grounds for Suspension. Revocation of Certification, or Refusal to Renew Certification and said issue will be forwarded to the Department of Public Health (Department), Office of Emergency Medical Service (OEMS) for investigation.
Date *
Date