We are pleased that you are seeking employment with Basit Ambulette. We are proud to be an Equal Opportunity Employer. Applications are considered withoutregard to race, color, religion, sex, age, sexual orientation, national origin, or any other factors prohibited by local, state, or federal law.
Note: To be considered for employment, please completely fill out the front and back of this application.
Application Date:
Name:
Address:
Phone Number:
SSN:
Are you a United States Citizen or are you authorized to work in the United States: Yes No
Are you willing to submit to pre-employment and random drug and alcohol tests: Yes No
Are you willing to submit to pre-employment background check: Yes No
Date you can start:
Have you served for any US Armed Forces? Yes No
Can you perform the essential functions of this job, with or without reasonable accommodations? Yes No
Can you meet the attendance requirements of this job? Yes No
High School:
College:
Trade School:
Did you graduate? Yes No
Year of graduation:
List any relevant subjects studied, special skills, certificates awarded:
Please list your last three emplyers, starting with the most recent, including military service.
Employer: Position:Salary:$perStart date:End date:Reason for leaving:Telephone:May we contact this previous employer? Yes No
List any other references we may contact, who have knowledge of you performance and work expericence:
Licence Number: Class: Endorsements: Restrictions:
Have you ever been disqualified to drive an ambulette byNYS, NYC, DOT, DMV, DOE, or any other government agency? Yes No
Have you ever had your license revoked or suspended for more than one year? Yes No
Does your license currently have FOUR or more demerit points in New York State? Yes No
If you answered yes to any of the above questions please explain on an additional page.
Do you authorize the Company to obtain and review your driving record abstract? Yes No
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answersgiven by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed thisapplication. I understand that any omission or misstatement of material fact on this application or on any document used to secure employmentshall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the Company to thoroughly investigate my references, work record, education, and other matters related to my suitability foremployment and, further, I authorize the references I have listed to disclose to the Company all letters, reports, and other information related tomy work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers, and other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of, or in any way related to, suchinvestigations or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted, or during m employment, ifhired, is intended to create an employment contract between the Company and me. In addition, I understand and agree that if I am employed, myemployment is "at will" and is for no definite or determinable period, and may be terminated at any time, with or without prior notice, or with orwithout cause, at the option of either myself of the Company, and that no promises or representations contrary to the foregoing are binding on theCompany unless made in writing and signed by me and the Company's President or designated representative.
I understand that in connection with my application for employment, the Company may obtain a consumer report and/or investigate consumerreports about me that may contain information as to my character, general reputation, personal characteristics, and mode of living. Such reportsmay include or consist of, but are not limited to, my driving history and/or conviction history obtained from the Department of Motor Vehicles. Ifurther understand that any job offer extended by the Company is contingent upon receipt of a favorable consumer or investigative consumerreport about me as well as a favorable driving and conviction history.
I understand that in connection with my application for employment, depending upon the position for which I have applied, any offer ofemployment is conditional upon my taking and passing a post-offer/pre-employment drug test and/or alcohol test, and if necessary for the positionfor which I have applied, a post-offer/pre-employment medical examination, and/or a post-offer/pre-employment physical performanceexamination along with driving skills written and road test (typically per NYS VTL Article 19-A compliance). I understand that I may refuse totake any required pre-employment drug test and/or alcohol and/or medical examination and/or physical performance examination and/ordriving skills written and road test, but that if I do, any offer of employment will be immediately withdrawn. Furthermore, I understand that as thisCompany is a contractor for government agencies, therefore in connection with my application for employment, depending upon the position forwhich I have applied, any offer of employment is conditional upon authorization and approval by such applicable government agencies, including,but not limited to, approval from New York City Taxi and Limousine Commission (TLC), NYC Department of Education (DOE/OPT), or anyother relevant agency. Failure to be approved to work for the Company by any government agency will result in my offer of employment beingwithdrawn.
If hired, I will provide proof of my legal authorization to work in the United States.
This application, when completed and signed, becomes the property of the Company.
I certify all of the information above is truthful and answered to the bestt of my ability. I have read the aboveparagraphs, understand their importance and effect upon my employment, and accept same as conditions ofmy employment with Basit Ambulette.
Signature:
Date: