LEBANON VALLEY SPEEDWAY & DRAGWAY

2008 APPLICATION FOR EMPLOYMENT

(AMBULANCE)

 

 

 

______________________________________________________________________________________

LAST NAME                                        FIRST NAME                          MIDDLE INITIAL

 

______________________________________________________________________________________MAILING ADDRESS (INCLUDE YOUR 911 ADDRESS)

 

______________________________________________________________________________________

CITY                                                   STATE                                    ZIP CODE

 

______________________________________________________________________________________

AREA CODE & PHONE NUMBER        CELL #                                        OTHER NUMBER

 

______________________________________________________________________________________

DATE OF BIRTH         AGE                 SEX                            SOCIAL SECURITY NUMBER

 

 

_____________________________________________________________________________________

PERSONAL REFERENCE AND PHONE NUMBER

 

______________________________________________________________________________________

EMERGENCY CONTACT PERSON                   PHONE NUMBER

 

______________________________________________________________________________________

E-MAIL ADDRESS

 

WHEN ARE YOU ABLE TO WORK?

_____  SPEEDWAY

_____  SATURDAY NIGHTS

_____  MIDWEEK EVENTS

_____  DRAGWAY

_____ WEDNESDAYS

_____ SATURDAY

_____ SUNDAY

                                                           _____ MIDWEEK EVENTS

 

HAVE YOU WORKED WITH US BEFORE? ____ YES ____ NO

 

 

PLEASE COMPLETE APPLICATION AND RETURN TO:

STEVE ROBELOTTO

 

PLEASE PRINT CLEARLY!

 THANK-YOU

 

 

P.O. Box 9, 1746 RT. 20 WEST LEBANON, NY 12195

PHONE: 1-518-794-9606        FAX: 1-518-794-7889

 

 

 

EMT APPLICATION

 

NAME:           ___________________________________________________

ADDRESS:    __________________________________________________

CITY:             __________________________________________________

STATE, ZIP:  ___________________________________________________

 

DIRVERS LICENSE #         ____________________

EXPIRATION DATE:           ____________________

SOCIAL SECURITY #          ____________________

 

HOME PHONE:       ____________________

WORK PHONE:        ____________________

CELL PHONE:        ____________________

PAGER:                    ____________________

 

EMT #                          _____________     CPR #                                   ______________

EXPIRATION DATE:  _____________     EXPIRATION DATE:  ______________

 

If you have HEP shots please give Date of Vaccination and sign:

Date:  _______________   Signature:  _________________________

 

If you refused your HEP shots please sign:

Signature:  _________________________

 

Your first night working you will need to bring Drivers License, EMT card, CPR card and Social Security Card so we can photo copy and place in your employee file.  You will receive a schedule and we will also point one in the Office by our note board.  Arrival times will be on schedule, please check because races start at different times during the season.