Graduate Ambulance Paramedic Application Form doc HRIS and ...

Graduate Ambulance Paramedic
Application Form
Please note:
1. Completion of this application form and compliance with its instructions forms part of your assessment.
2. Please note: if you choose to supply originals of documents, they cannot be returned. Certified copies
of your originals are recommended
3. CERTIFICATION OF DOCUMENTS:
Where indicated, certified documents are required as part of this application. A certified copy means
your original and photocopy have been sighted together by an authorised person who verifies the copy
as a true and correct reproduction of the original. Persons authorised to certify documents include
Doctors, Pharmacists and Police Officers.
! To ensure that you have filled out this application form correctly and for more information regarding
the GAP recruitment process, please make sure that you have downloaded and read the
accompanying document titled, “GAP Recruitment Process Information”
Please send to:
Or deliver to:
Graduate Ambulance Paramedic – Confidential
Recruitment Team
Ambulance Victoria
PO Box 2000
DONCASTER VIC 3108
375 Manningham Road, Doncaster
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OD142

Your Details
Surname
First Name
Address
Postcode
Email
(NB: AV is unable to send to AOL email addresses)
Telephone (AH) (BH) (Mob)
Please place an asterisk (*) next to your preferred contact number.
! Please note: much of our correspondence to you during the selection
process will be via email, so please check for new mail regularly and turn off
your spam/junk mail filters to ensure our email gets to you.
Right to Work in Australia
Are you an Australian or New Zealand Citizen or the holder of
an unrestricted working rights visa?
Yes
No
Please attach a certified copy of one of the below documents as proof of your right to work in Australia:
• Australian Birth Certificate
• Australian Citizenship Certificate
• Evidence of Residency/Visa status
• Australian or New Zealand Passport
Driver’s Licence
Applicants for Ambulance Paramedic roles must hold a P2 probationary driver’s licence that has been held for at
least one year or more, or a full driver’s licence.
Please direct all licence enquiries to Vic Roads on 13 11 71 or www.vicroads.com.au
Applicants who do not meet this requirement prior to commencing employment with AV may be put on an
eligibility waiting list. Please contact AV to discuss further.
Licence Number:
State Issued:
Date license issued:
Licence expiry date:
Number of Years on
Green P Plate :
P Plate expiry date:
(if applicable)
(if applicable)
! IMPORTANT: Please attach a certified photocopy of BOTH sides of your licence
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GAP Recruitment Application

Driving Offences
Have you ever had your drivers licence suspended or cancelled? Yes No
If yes, please give details including at what level your licence was reinstated (full or probationary) and what month
and year.
Are there currently any outstanding charges or other matters which may impact on you continuing to hold a current
unrestricted Victorian Drivers Licence?
If yes, please provide details below: Yes No
If your application is progressed, it is your responsibility to immediately notify the Recruitment Team of loss of
licence, charges laid or notification of impending action which may result in loss of licence.
Verification of Driving History
Applicants are requested to provide a 5 year Verification of Driving History report from your relevant Road Traffic
Authority(s) (e.g. VicRoads). The report should include a statement of demerit points and convictions against the
licensee and is at your expense (approximately $8.10 in Victoria).
Applicants who have lived in a different state or country to their current home address for 12 months or longer
during the last five years should provide reports from those states or countries to cover that period.
! IMPORTANT – Two reports are required:
1. Current status of demerit points
2. Licence Conviction Record
Police Records Check
! You are required to obtain a National Police Record Check and submit to Ambulance Victoria.
Please go to; www.police.vic.gov.au for further information. We also accept Federal Police Checks.
National Police Record Check completed online? Yes No
! If your application is progressed, it is your responsibility to immediately notify the Recruitment Team of any
criminal charges being laid against you.
Voluntary Departure Package Declaration
I _________________________________________ HAVE / HAVE NOT been the recipient of a Voluntary
Departure Package or equivalent from the Victorian State or Federal Public Service (Insert your name and circle
appropriate answer).
If you have accepted a VDP please provide a copy of documentation showing acceptance date and
exclusion period.
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GAP Recruitment Application

Ambulance Qualification
Name of Course/Qualification:
(Please indicate degree type
(e.g.: Single, Double, Conversion))
University Name:
Year of Completion:
Are you a graduate of a double degree in Bachelor of Nursing / Bachelor of
Paramedicine?
Yes
No
If yes, are you interested in AV’s Inter-Professional Graduate (IPG) Program? Yes No
Please note; the Inter-Professional Graduate Program (IPG) is only available to graduates of Bachelor of Nursing / Bachelor
of Paramedicine double degree . Applicants expressing interest in the IPG Program must successfully complete all elements
of AV’s Graduate Ambulance Paramedic recruitment process in order to be considered for the IPG program. If your application
is unsuccessful for a Graduate Ambulance Paramedic position, you will no longer be considered for the IPG program.
Applicants who express interest in the IPG Program will not be disadvantaged in the application process for AV’s GAP
program. All eligible applicants will be notified directly regarding further information about our current IPG Program.
! Please provide a certified copy of the front and back of a current transcript which shows your latest
results and current subjects being undertaken.
Please note: your employment is subject to achieving successful overall results in your course subjects.
Ambulance Victoria Employees
Have you previously or are you currently employed by Ambulance Victoria?
(Including Rural Ambulance Victoria or Metropolitan Ambulance Victoria)
Yes
No
If Yes, please provide the following details:
Start Date:
End Date: (If applicable)
Employment Title:
Location:
Employee number:
If you are no longer with Ambulance Victoria, please provide details around why you ceased employment with us:
Please note that internal reference checks will be completed for all current and previous AV employees
and volunteers.
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GAP Recruitment Application

Pre-existing Injury or Medical Condition Declaration
Employment with Ambulance Victoria (AV) is conditional on the applicant being a fit and proper person and fully
able to perform the inherent requirements of the position. When completing the pre-existing injury or medical
condition declaration it must be in full knowledge of the position as outlined in the Position Description and the
Physical Requirements Information sheet. The Graduate Ambulance Paramedic Position Description and the
Physical Requirements Information sheet are both available for download from our website
www.ambulance.vic.gov.au. Read the documents carefully and discuss any queries that you may have prior to
completing the form with the Recruitment Team,
The primary purpose of this declaration is to assist AV in ensuring that no person is placed in an environment or
given tasks that will place their Health and Safety at risk. It is not the intention of this declaration to deny a person
employment solely because of disability or illness. You may be required to have a medical examination with a
medical practitioner nominated by AV to check your capacity to safely perform all components of the work.
Please read and consider all the requirements of the position before completing this section of the application form.
The pre-existing injury or medical condition declaration does enable, where applicable, appropriate and reasonable
action to be taken by AV to meet the provisions of Sections 82(7) and (8) of the Accident Compensation Act 1985
and Section 21 of the Occupational Health and Safety Act 2004.
Section 82(7) and (8) of the Accident Compensation Act 1985, requires disclosure to your employer of any preexisting
injuries or disease that you have suffered, or existing injuries or disease that you continue to suffer of
which you are aware and could reasonably be expected to foresee, and could be affected by the nature of the
proposed employment referred to above.
Section 21 of the Occupational Health and Safety Act 2004, states that an employer shall provide and maintain, so
far as practicable, for employees a working environment that is safe and without risks.
Failure to make a disclosure, or the making of a false or misleading disclosure, may disentitle you to compensation
pursuant to the Accident Compensation Act 1985 should you suffer any recurrence, aggravation, acceleration,
exacerbation or deterioration of a pre-existing injury or disease arising from employment with AV.
This pre-existing injury or medical condition declaration also assists AV to obtain information to enable it to meet
its obligation under the Equal Opportunity Act 2010 to make reasonable adjustments for an employee or
prospective employee in order to perform the genuine and reasonable requirements of the employment.
Privacy Notice: The collection and processing of this information is in accordance with the Occupational Health
and Safety Act 2004, the Accident Compensation Act 1985 and the Equal Opportunity Act 2010.
The completed pre-existing injury or medical condition declaration will be retained on your personnel file. Where
employment is not taken up, for whatever reason, all documents relating to your application will be retained for six
months after the finalisation of any appointment appeal and then destroyed.
AV may disclose some of your personal information, as applicable; to an independent medical examiner should we
require an assessment of your suitability for employment and fitness for duty. Your health declaration may be also
be disclosed to the AV’s WorkSafe insurer should you submit a WorkSafe claim for compensation.
Further information regarding AV’s Privacy Policy is available on page 11 of this application form.
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GAP Recruitment Application

You are requested to disclose all pre-existing injuries and medical conditions of which you are aware and could
reasonably be expected to foresee could be affected by the nature of your proposed employment.
Are you aware of any circumstances regarding your health or capacity to work that would interfere with
your ability to perform the duties of a Graduate Ambulance Paramedic?
In answering this question Yes or No you are also covering factors such as: existing or exposure to infectious
diseases, taking of medication/treatment on a regular basis (daily, weekly, monthly) If yes, what adjustments do you
need to perform the genuine and reasonable requirements of the employment (if any)?”
NO [ ] YES [ ]. If yes, please provide the following details for each circumstance including:
(i) Nature of injury/medical condition
(ii) Date of injury/medical condition
(iii) Duration of injury/medical condition
(iv) Has the injury/medical condition resolved and if so, when? (If insufficient space, please attach details on A4
paper)
Do you have an existing injury or medical condition or pre-existing injury or medical condition that could
be affected by the nature of the proposed employment?
Existing is a condition for which treatment is still being received. Pre-existing is where an injury or condition/s is
present but treatment is not required. If yes please provide details of the injury or condition(s). If yes, what
adjustments do you need to perform the genuine and reasonable requirements of the employment (if any)?”
NO [ ] YES [ ]. If yes, please provide details:
EMPLOYEE DECLARATION
I, ______________________________ of __________________________________________________________
(Applicant’s Name)
(Applicant’s Address)
do sincerely declare that the contents of this form are true and correct and complete to the best of my knowledge
and no information concerning my past or present state of health has been withheld. I hereby agree to undergo a
health assessment by a medical practitioner if deemed necessary by Ambulance Victoria.
I understand that any willfully incorrect or misleading answer or material omission which relates to any of the
questions before mentioned may make me ineligible for employment, or if employed, liable to disciplinary action
which may include dismissal. I understand that this pre-existing injury or medical condition declaration may form
part of my employee file.
I have read the Position Description and the Physical Requirements Information Sheet and understand the
requirements of the role of a Graduate Ambulance Paramedic.
Signature: Date: / /
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GAP Recruitment Application

Employment History
Please provide details of your paid employment history - beginning with your most recent position. If insufficient
space is provided, please attach further details. Please also include details about any gaps in your employment
history i.e. family, travel, study, unemployed etc.
Alternatively, feel free to attach a copy of your CV or resume that includes this information.
Position Held:
Employer Name:
Address:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
Position Held:
Employer Name:
Address:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
Position Held:
Employer Name:
Address:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
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GAP Recruitment Application

Volunteer History
Please provide details of any volunteer work or community contribution that you are currently or have been
involved in. If insufficient space is provided, please attach further details.
If you are currently volunteering with AV, and have over 2 years of service with us, you may be able to apply via
AV’s ACO-GAP program.
Volunteering Capacity:
Organisation:
Supervisor name:
Contact details:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
Volunteering Capacity:
Organisation:
Supervisor name:
Contact details:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
Volunteering Capacity:
Organisation:
Supervisor name:
Contact details:
Date Commenced: / /
Summary of Main Duties:
Date Ceased:
(If applicable)
/ /
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GAP Recruitment Application

Region and District Preference Form
Please indicate your preference for your Graduate training location, from 1 – 18.
This will be your work location until you complete the Graduate Ambulance Paramedic Program, and achieve
independent practice (usually the first 12 months of your employment with us).
Towards the middle of your GAP program, you should discuss your options for your post-GAP branch location with
your Team Manager, to give you the best chance of relocating to the location you prefer.
Metro
Metro - East
Metro - West
Barwon (i.e. Geelong cluster, Lorne)
Barwon
South West
South West (i.e. Mortlake, Colac, Warrnambool, Apollo Bay)
Southern Grampians (i.e: Portland, Hamilton, Casterton)
Loddon (i.e. Bendigo, Castlemaine, Gisborne, Kangaroo Flat, Kyneton, Maryborough, Romsey )
Loddon
Mallee
Campaspe (i.e. Echuca, Kyabram)
Northern Mallee (i.e. Irymple, Mildura, Swan Hill)
Grampians
Central Grampians (i.e. Avoca, Ararat, Daylesford, Wendouree, Ballarat)
Wimmera (i.e. Horsham, Nhill, Warracknabeal, Edenhope)
Upper Hume (i.e. Wodonga, Beechworth, Corryong, Mount Beauty)
Hume
Central Hume (i.e. Yarrawonga, Benalla, Mansfield, Wangaratta, Bright, Myrlford)
Western Hume (Cobram, , Mooroopna, Shepparton, Euroa)
Southern Hume ( Seymour, Kilmore, Yea)
South Coast (Cowes, Leongatha, Warragul, Wonthaggi)
Gippsland
Wellington (Moe, Morwell, Sale, Traralgon)
East Gippsland (Bairnsdale, Lakes Entrance)
Anywhere*
Any regional AV branch
! Anywhere*: The Anywhere option should only be selected if you are genuinely willing to move anywhere in the
state. As Ambulance Victoria is a state-wide service, it is important that we are always adequately staffed in all
locations to provide services to all Victorian communities. Selecting the “Anywhere” option does not fast track you
to a job offer, nor does it disadvantage you if you don’t choose this option.
! Please remember that working with AV as a Graduate Ambulance Paramedic your leave roster blocks are
structured. You will be informed of your leave on commencement. It is not possible for our GAPs to take leave prior
to these designated timeframes.
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GAP Recruitment Application

Your Referees
Your Name
Your Contact
Number
AV requires at least two professional references in support of your application. Referees need to be supervisors
or managers who have had a close and recent involvement in your work, and should include your current
manager, if you have one. Employment can be paid or as a volunteer. Please note, referees cannot be related to
you by birth, marriage or de facto relationship.
AV prefers to contact referees via e-mail. If this is not possible, please provide a relevant contact
number. Please make sure your referee is anticipating contact from AV and is willing to participate as a
reference.
Name:
(Current/Recent Supervisor/Manager)
Organisation:
Position:
Relationship:
(Reporting
Relationship)
E-mail
address:
Telephone:
Name:
Organisation:
(BH)
(Current/Recent Supervisor/Manager)
(Mobile)
Position:
Relationship:
(Reporting
Relationship)
E-mail
address:
Telephone:
Name:
Organisation:
(BH)
(Current/Recent Supervisor/Manager)
(Mobile)
Position:
Relationship:
(Reporting
Relationship)
E-mail
address:
Telephone:
(BH)
(Mobile)
I ____________________________, give permission for the AV to conduct referee checks with the people I have
listed above.
Signature Date / /
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GAP Recruitment Application

University Consent
Consent to Release Course Progress Information to Ambulance Victoria
AV requires universities to provide feedback on the progress of your study, to enable us to monitor the
performance of all prospective and current AV staff undergoing training provided by universities.
All student information disclosed to AV in accordance with this Consent Form will be managed in accordance with
the requirements of the Information Privacy Act 2000. Information collected from you will be placed onto your AV
training file. AV Policy Odpol007 “Storage and Access to Personnel Files” provides details of how to access
information held on this file.
It is your responsibility to provide AV with transcripts as required; this consent will be passed to the
relevant university if required. By signing this consent, it does not mean that AV will contact universities
for your results on your behalf.
I, ______________________________ grant Ambulance Victoria (AV) consent to obtain course progress
information from my university, with any details pertinent to my progress in my course of studies.
This includes grades received on any assessment item, class attendance and level of participation.
Signature: Date: / /
Certification/Acknowledgement
I certify that the information contained in this application is correct to the best of my knowledge. Furthermore, I
authorise Ambulance Victoria to conduct any background verification checks as deemed necessary in connection
with this application. This includes referees, educational history, employment history, Police and Driving checks.
Signature: Date: / /
Privacy Statement
By applying for employment with AV, you give your consent for AV to collect and store information relevant to
your application, to use and disclose it as necessary to process your application (including referee and police
checks) and, if your application is successful, to hold information necessary for the management of your ongoing
employment with AV.
AV collects only what is necessary for the above processes and stores all information securely, in keeping with
the Requirements of the Information Privacy Act 2000, the Health Records Act 2001, and the Public Records Act
1978. Only authorised AV staff can access the information that AV holds about you. You can request access to
personal information that AV holds about you by telephoning (03) 9840 3500 to obtain a copy of the full Privacy
Policy or read it online at http://www.ambulance.vic.gov.au
I consent to all of the information provided in this application including the results of any testing being
maintained in AV’s records.
Signature: Date: / /
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GAP Recruitment Application

YOUR CHECKLIST Included N/A
Awaiting
All sections of the application correctly completed and signed
Certified proof of right to work in Australia (Passport/ / visa / Birth Certificate)
Certified copy of front and back of your driver’s licence
Original or certified copy of Driving History
Original or certified copy of National Police Record
Voluntary departure package declaration completed & information
Original or certified copy of most recent Academic Transcripts
Pre-existing injury/medical condition declaration signed and dated
Complete Employment History documented and gaps in history explained.
CV enclosed if preferred.
Complete Volunteer History – contact details provided so AV can confirm
Graduate Program Location Preference completed
Request for AV Applicant Referee Information - email details listed
University Consent Competed
Certification / Acknowledgment is signed and dated
Privacy Statement signed and dated
! Remember, much of our correspondence to you during the selection
process will be via email, so please check for new mail regularly and turn off
your spam/junk mail filters to ensure our email gets to you.
We will contact you in writing to acknowledge your application within 7-10
days.
AV’s graduate recruitment process is a complex process, and we receive
many hundreds of applications each year. It will sometimes take us a while to
contact you with arrangements for each stage, so please be patient with us.
Thanks for your interest in joining the AV team, and best of luck!
TRIM: HUM/29/106-2
GAP Recruitment Application