LPVAS Employee Application Name * Name First First Last Last Address * Date of birth * Email * Phone * Residential Status * Year-round Temporary Summer Winter If not year-round, please explain Salary desired * $/year Position Desired * Full-time Part-time Per diem AEMT-CC AEMT-P EMT/Driver Available Start Date * Date, Month, Year Shifts Available * Days Nights Weekdays Weekends Are you currently employed? * YesNo If yes, may we contact your employer? If yes: name, email address, and phone number of employer Have you applied to LPVAS before? * YesNo If so, when? Driver’s License Number * Driver’s license state and class * ex: NY Class D NYS EMT# * NYS EMT Expiration * Please list all other current certifications and expiration dates * Other volunteer activities, certifications, awards, recognition * Have you ever been convicted of a felony? * Yes No *You will not be denied membership solely because of a conviction record unless the offense is related to the position for which you have applied Education and Licenses: High School School name, years attended, graduated (Y/N), degree Education and Licenses: College School name, years attended, graduated (Y/N), degree Education and Licenses: Trade/Business School name, years attended, graduated (Y/N), degree Education and Licenses: Military School name, years attended, graduated (Y/N), degree Employment History * Date (month and year), name and address of employer, salary, position, and reason for leaving References: Person should not be related to you, whom you have known at least one year (1/3) * Name, address, phone number References: Person should not be related to you, whom you have known at least one year (2/3) * Name, address, phone number References: Person should not be related to you, whom you have known at least one year (3/3) * Name, address, phone number Sign your name here * “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liabilities for any damage that may result from furnishing the same to you. I understand and agree that if hired, my employment is for no definite period and may regardless of date of payment of my wages and salary be terminated at any time without prior notice” Date submitted * If you are human, leave this field blank. Submit