Please remember to dial 911 in any emergency PVEA Online Application Step 1 of 18 5% 1. Positions of Interest:Date* MM slash DD slash YYYY Check positions of interest* Volunteer/EMT-B Volunteer / EMT-P Per-diem/EMT-B Per-Diem/EMT-P Full-Time / EMT-B Full-Time/EMT-P Administrative Who referred you to this position? 2. Personal Information:Your Name* First Middle Last Suffix List all other names by which you have been known…(Applicants should list maiden name also) Are you 18 or older?* Yes No If hired, can you present evidence of your identity and legal right to work in this country?* Yes No 3. EMS Education:Check all that apply Not applicable Enrolled/Interested in EMT class EMT – Basic Certification EMT – Paramedic Certification Regional approved preceptor Check if you have additional titles / diplomas to list: Which school, class or region are you enrolled or interested in?* Which school, class or region did you achieve your EMT-Basic Certification?* EMT- Basic Certification Date* MM slash DD slash YYYY Which school, class or region did you achieve your EMT – Paramedic Certification?* EMT – Paramedic Certification Date* MM slash DD slash YYYY Which school, class or region did you achieve your regional approved preceptor?* Regional approved preceptor Date* MM slash DD slash YYYY List your additional titles / diplomas:* 4. EMS Clearance Background: (Not applicable for Auxiliary/Administrative)Are you an RSI provider?* Yes No Check level if applicable EMT - Basic EMT - Paramedic Initial NYS Certification Issued* Region Initially Cleared & Date* Regions currently cleared at* 5. Minimum salary desired (Per-diem & Full time only)Per Hour 6. AddressAddress* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How long have you lived at your current address?* 7. Contact InformationHome PhoneCell PhoneEmail 8. Clearance:(Not applicable to Auxiliary/Administrative) - Physical examination may be required at no out-of-pocket cost.Will you be willing to undergo a medical examination?* Yes No Will you be willing to undergo a drug test?* Yes No Do you meet and can comply with NYS requirements of Article 30 Part 800?*Article 30 Part 800(link opens in new window) Yes No Can you comply with NYSDOH Bureau of EMS Policy Statement 00-10 Functional Position Description?*NYSDOH Bureau of EMS Policy Statement 00-10(link opens in new window) Yes No 9. Availability:(Not applicable to Auxiliary/Administrative) - Check all that apply and indicate your availabilityDays Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours* Open availability Limited availability listed below List hours of availability:* 10. Driver License:(Not applicable to Auxiliary/Administrative)Driver’s License Number:* Issuing State:* Class of License:* Expiration Date:* MM slash DD slash YYYY Conditions / Restrictions:* Yes No If Yes, list restrictions:* 11. Additional Certifications EMS EducationCertification(s) Aquired:(Check all that you've aquired) NIMS 100 NIMS 200 NIMS 700 NIMS 800 ITLS/PHTLS ACLS PALS CPR EVOC / CEVO Other NIMS 100 expiration date, if applicable MM slash DD slash YYYY NIMS 200 expiration date, if applicable MM slash DD slash YYYY NIMS 700 expiration date, if applicable MM slash DD slash YYYY NIMS 800 expiration date, if applicable MM slash DD slash YYYY ITLS/PHTLS expiration date, if applicable MM slash DD slash YYYY ACLS expiration date, if applicable MM slash DD slash YYYY PALS expiration date, if applicable MM slash DD slash YYYY CPR expiration date, if applicable MM slash DD slash YYYY EVOC / CEVO expiration date, if applicable MM slash DD slash YYYY List other certifications / expiration dates not checked above:* 12. Current Employer:Name of Employer Supervisor May we contact? Yes No Employer Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date Employed (from month/year to month/year): Job Title and Duties Reason for leaving?Do you have another current position to list? Yes No List other current positions here:(Click the '+' symbol to add another row if needed)Name of EmployerSupervisorMay we contact? (yes or no)Phone #Date Employed (mo/yr):Title / DutiesReason for leaving? 13. Have you ever been involuntary terminated or asked to resign from any job?Please answer with Yes or No* Yes No 14. Are there any gaps in your employment history?Please answer with Yes or No* Yes No 15. If you answered yes to either question 13 or 14 please explain below with dates* 15. Emergency Response Experience: (Fire-Rescue, Police or EMS)List all Agencies including past employments. Undisclosed information may result in termination.Name of Agency Contact Person May we contact? Yes No Agency Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Agency Phone NumberDates of service (from month/year to month/year): Job Title and Duties Reason for leaving?Do you have another previous Fire-Rescue, Police or EMS position to list? Yes No List other previous Fire-Rescue, Police or EMS positions here:(Click the '+' symbol to add another row if needed)Agency nameContact personMay we contact? (yes or no)Phone #Service dates (mo/yr):Title / DutiesReason for leaving? 16. Personal References (not family related):Reference #1:Name:Contact #:How acquainted:Years known: Reference #2:Name:Contact #:How acquainted:Years known: Reference #3:Name:Contact #:How acquainted:Years known: 17. Additional Information:Comments: 18. Certification:I hereby state that all of the above questions have been answered truthfully and without gross omission. I authorize PVEA to check my references and/or all of the above with proper law enforcement agency. I also understand that willful falsification or omission from this application will be cause for rejection or dismissal. It is further understood that this application will be handled in accordance with the Civil Rights Act of 1964 and no discrimination will occur because of age, sex, religion, race, gender, sexual orientation, national origin or any other protected classification.Your Name* First Middle Last Suffix Signature:*(Sign with finger or mouse pointer) 19. Privacy Notification:Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor?* Yes No If you answered yes please explain below with dates:*APPLICANT’S AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I, the applicant signing this form, do hereby authorize a review and full disclosure of records concerning myself to PVEA, the Monroe County Sheriff’s Office and designated persons working on their behalf, whether the information be of public, private, or confidential nature; and I release them from any liability and responsibility from doing so. The intent of this authorization is to give my consent for full and complete disclosure of records of all licensing agencies, educational institutions, and law enforcement agencies. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release of authorization will be considered in determining my suitability for membership / employment of PVEA. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release the PVEA, and the Monroe County Sheriff’s Office from any and all liability which may be incurred as a result of collecting such information. A PHOTOCOPY OF THIS RELEASE WILL BE AS VALID AS AN ORIGINAL THEREOF, EVEN THOUGH THE SAID PHOTOCOPY DOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE. I have read and fully understand the contents of this “Authorization for Release of Personal Information.”Applicant Signature:*(Sign with finger or mouse pointer)Applicant Signature Date:* MM slash DD slash YYYY Δ
