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  • List below all of your EMS training, where you received this training and how many hours of instruction you have received:
  • Date Format: MM slash DD slash YYYY
  • Please list 3 references (not relatives)

  • Reference #1

  • Reference #2

  • Reference #3

  • Following is a list of requirements and/or responsibilities of Ambulance Service Members:

    1. You must be able to assist lifting the ambulance cot with a patient. The total weight would be approximately 100 pounds. The cot with patient would be lifted from the ground to the ambulance floor (approx. 3 feet).

    2. You will be required to take a minimum of 24 hours of call per month and 12 Holiday call hours in a year.

    3. You will be required to attend no less than 8 of the 12 monthly meetings and training sessions.

    4. You will be required to pass a physical examination as described by our Medical Director.

    5. You must live in or work within 10 minute drive time to ambulance garage.

    I authorize investigation of all statements contained in this application for employment as may be necessary to determine eligibility for employment. I certify that answers given herein are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I understand and agree that, if hired, my employment is for no definite period and may be terminated at any time. Applicant may be subject to a random drug screen.

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  • Informed Consent

  • General Authorization and Release Pursuant to Minnesota Statutes §13.05, Subd. 4, Minnesota Data Practices Act

    I hereby authorize and grant my informed consent to permit the release of data to the police department serving the City of Madelia, Minnesota, and/or its agent and/or representatives, data classified as private which concerns me and that may be in your possession. The data which I authorize to be release consists of private data as define by Minnesota Statutes §13.04, Subd. 12, and has been collected by you as a result of my contacts and associations with you and/or your representatives. The information from which release is authorized includes all data which has been collected, created, received, retained, or disseminated in whatever form which in any way relates to my dealings with you or your agency. I understand that the following types of data are among those pertinent to the review of my employment applications: educational records, military record, employment data (current and former), arrest records, conviction records, professional and personal references, and driver’s license records. I understand that the purpose of permitting the City of Madelia to have access to this information is to determine my suitability for employment.

    I understand that any decision to hire me is contingent upon the results of an investigatory report. I further understand that misrepresentation or omission of information will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I hereby release any person who provides information pursuant to this document from any claims or liability by me or on my behalf.

    By signing this authorization, I hereby release the Police Department serving the City of Madelia and the Bureau of Criminal Apprehension from any and all liability which otherwise may or does happen as a result of the release of any and all data, regardless of its accuracy. I also release the City of Madelia from any and all liability for its receipt and use of data received pursuant to their consent.

    This authorization or a copy of this authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to the expiration, cancel the written authorization by providing written notice to the City or to you of that fact.

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  • Applicant Information

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