Application for Paramedic Employment

APPLICATION FOR PARAMEDIC EMPLOYMENT

INSTRUCTIONS / OFFICE USE ONLY
Please complete all sections as thoroughly as possible and be sure to include the documents as requested in Section 7. It is necessary to provide complete information as this will be used to determine eligibility and qualifications for employment. A separate application is required for each competition.
The personal information requested on this form is collected and managed as per the Municipal Freedom of Information and Protection of Privacy Act, R. S. O. 1990. All information provided to us is considered supplied in confidence. / RECEIVED:
Section 1: POSITION INFORMATION
Position Title: / Competition/Posting #:
Date Available for Work: / Type of Position Preferred:
Full-time Part-time Casual
Preferred Work Locations:
Pickle Lake Sioux Lookout Ignace Dryden Red Lake
Ear Falls Sioux Narrows Kenora Nestor Falls
Section 2: PERSONAL INFORMATION
Last Name: / First Name: / Middle Initial(s):
Mailing Address: / City: / Province: / Postal Code:
Primary Phone Number: / Alternate Phone Number:
E-Mail Address:
What is your legal status to work in Canada? Supporting documentation may be required.
Canadian Citizen Landed Immigrant/Permanent Resident Work Permit Other (specify): ______
Have you ever been convicted of a Criminal Offence for which you have not received a pardon or that prohibits you from working under the position you are applying for? Yes No
Please note: Offers of employment are conditional upon providing an acceptable Criminal Records Check including Vulnerable Sector Screening.
It is the KDSB’s policy that familial relationships do not form the basis of an employment decision within the organization. As such, the Board prohibits employment situations (certain exceptions apply) where family members would be directly supervised by or directly subordinate to one another, be given preferential treatment in being recruited and/or selected for vacancies, or be appointed to positions where job responsibilities would be incompatible with positions occupied by family members (KDSB Policy HR-II-07).
Do you have any relatives who work for the Kenora District Services Board? Yes No
If yes, please provide name(s) and your relation to him/her:______
______

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Section 3: EDUCATION, TRAINING, AND PROFESSIONAL ASSOCIATIONS
Please provide details of secondary and post-secondary education, courses, and training that have given you work-related knowledge, skills, and/or abilities starting with the highest level achieved. Attach an additional page if necessary. Please note: Offers of employment are conditional upon providing proof of education noted below.
Name of Institutionor Organization / Area of Study/Course / Duration
mm/yy to mm/yy / Completed?
Please circle
______to ______/ Y / N
______to ______/ Y / N
______to ______/ Y / N
______to ______/ Y / N
Please provide the names of any related professional associates to which you belong:
______
______
Section 4: EMPLOYMENT HISTORY
Have you previously applied for employment with the Kenora District Services Board?
Yes NoIf yes, when (mm/yy): ______
Have you previously worked for the Kenora District Services Board? Yes No
If yes, when (mm/yy): ______Who was your supervisor? ______
Beginning with your current/most recent employer, provide details of your employment history. You may wish to include relevant volunteer positions. Please list every employer for the last ten years or your last four employers, whichever is greater. Attach an additional page if necessary.
1 / Name of Employer and Location: / From (mm/yyyy): / To (mm/yyyy) or “current”:
Supervisor’s Name: / Supervisor’s Telephone Number: / Supervisor’s E-mail Address:
May we contact him/her for a professional reference?
Yes No / Position Held by Applicant: / Reason for Leaving:
Duties and skills as they relate to the position for which you are applying:
______
______
______
2 / Name of Employer and Location: / From (mm/yyyy): / To (mm/yyyy) or “current”:
Supervisor’s Name: / Supervisor’s Telephone Number: / Supervisor’s E-mail Address:
May we contact him/her for a professional reference?
Yes No / Position Held by Applicant: / Reason for Leaving:
Duties and skills as they relate to the position for which you are applying:
______
______
______
3 / Name of Employer and Location: / From (mm/yyyy): / To (mm/yyyy) or “current”:
Supervisor’s Name: / Supervisor’s Telephone Number: / Supervisor’s E-mail Address:
May we contact him/her for a professional reference?
Yes No / Position Held by Applicant: / Reason for Leaving:
Duties and skills as they relate to the position for which you are applying:
______
______
______
4 / Name of Employer and Location: / From (mm/yyyy): / To (mm/yyyy) or “current”:
Supervisor’s Name: / Supervisor’s Telephone Number: / Supervisor’s E-mail Address:
May we contact him/her for a professional reference?
Yes No / Position Held by Applicant: / Reason for Leaving:
Duties and skills as they relate to the position for which you are applying:
______
______
______
Section 5: OTHER INFORMATION
Please describe any other information which might help us evaluate your candidacy (summarize why you believe you qualify for the position(s) for which you have applied):
______
______
______
______
Section 6: REFERENCES
Reference checks will be conducted to assess your past work performance and may include checks of attendance records. In addition to the references you authorized us to contact in the “Employment History” section, you may wish to provide further references. Between this section and the “Employment History” section, a total of 3 professional references must be provided. These individuals must be those in a managerial position wherever possible.
1 / Name and position: / E-mail Address: / Phone Number:
Relationship (i.e. manager) / No. of Years Known:
2 / Name and position: / E-mail Address: / Phone Number:
Relationship (i.e. manager) / No. of Years Known:
3 / Name and position: / E-mail Address: / Phone Number:
Relationship (i.e. manager) / No. of Years Known:
Section 7: PROOF OF QUALIFICATIONS
As part of your Application for Paramedic Employment with Kenora District Services Board – Northwest Emergency Medical Services, the following documents must be included with your application to be considered for employment (please check () all those that are included):
Cover letter and resume
College Diploma (or a letter from college confirming graduation date)
High School Diploma (or official transcript)
AEMCA Certificate or letter of registration to write AEMCA testing
Current CPR-Level C Certification
Class F Driver's License (front and back)
MOHLTC mandatory training record or letter from college confirming mandatory training was received.
Proof of Immunization for the following:
Measles, Mumps, Rubella
Diphtheria, Polio
Chicken Pox
Hepatitis B
Tetanus (issued within last 10 years)
Influenza
Proof of the following requirements is preferred but not required as part of your application (please check () those that are included):
Driver’s Abstract – 3 year search issued within the last 60 days
Copy of any relevant certifications (i.e. Base Hospital Certifications, Basic Trauma Life Support, etc.)
Criminal Record Check including Vulnerable Sector Screening - issued within the last 90 days
Proof of completion of the following training/courses are considered an asset during the candidate selection process as Northwest EMS Primary Care Paramedics are CPAP, King LT, and 12 Lead certified (please check () those that are included):
12 lead ECG certification/education with STEMI recognition training
Continuous Positive Airway pressure (CPAP) training/certification
Supraglottic airway training/certification (King LT airway)
Section 8: AGREEMENT
Please read carefully before signing. This application is not valid unless your name, as authorization, is signed in the “signature” space provided below. (Note: If this application is submitted electronically, please type in your name to validate the form).
I certify that the information provided in this application and any attachments to it are true and complete. I understand that any false statements or deliberate omissions made by me on this application or attachments may be sufficient cause for the cancellation of the application and, if I have been employed, for the immediate dismissal from the Kenora District Services Board.
X ______
Signature of Applicant / ______
Date Signed (dd/mm/yyyy)
FOR OFFICE USE ONLY
HIRING NOTES:

Kenora District Services Board – Application for Employment Page 1 of 4