Application For Employment
Please take a few moments to complete the on-line application for employment provided here. We consider applicants without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

*Denotes a required field

I - Applicant Information

* Last Name
  		* First Name
  		  MI
 
* Email Address
  		* Home Telephone #
  		  Mobile Telephone #
 
* Address
 		 * City
  		* State
  		* Zip Code
 
* Preferred employment status:
Full Time Part-Time
How did you learn about us?
Newspaper Friend Relative
Other
* If you are under 18 years of age, can you provide required proof of your eligibility to work?
Yes No
* Have you ever filed an application or been employed with us before?
Yes No
If you have been previously employed by MED-TECH, please give dates (Years only).
Start    End   
* Are you currently employed?
Yes No
* Are you prevented from lawfully becoming employed in this country because of a limited visa or immigration status?
(Proof of citizenship or immigration status will be required upon employment)
Yes No
* What date would you be available for work?
* Would you consent to drug testing if required for this position?
Yes No
Use the area below to outline any additional information about yourself that you feel may be helpful to us in considering your application, i.e., typing speed, skills, etc.

II - Employment History

Please input the following information for your previous 3 employers. Start with you current or most recent employer. Please note that all information is required in order for your application to be considered.

Employer #1 (Most Recent)
* Company Name:
Allow MED-TECH Resource, Inc. to contact your PRESENT employer.
* Job Title: * Hourly Salary:
* Work Performed:
  *Employer's Address:
  * Contact Name:
 
 *Contact Title:
 
 *Contact Phone:
 
* Reason for Leaving:
* Dates Employed: (Years only)
From         To   


Employer #2:
* Company Name:
* Job Title: * Hourly Salary:
* Work Performed:
  *Employer's Address:
  * Contact Name:
 
 *Contact Title:
 
 *Contact Phone:
 
* Reason for Leaving:
* Dates Employed: (Years only)
From         To   


Employer #3:
* Company Name:
* Job Title: * Hourly Salary:
* Work Performed:
  *Employer's Address:
  * Contact Name:
 
 *Contact Title:
 
 *Contact Phone:
 
* Reason for Leaving:
* Dates Employed: (Years only)
From         To   


III - Personal References

Please list two personal non-related references who do not live with you.

Personal Reference 1
* Name:   *Phone #:
 
* How Long Known?:   *Best Time To Contact?:
 
Comments:


Personal Reference 2
* Name:   *Phone #:
 
* How Long Known?:   *Best Time To Contact?:
 
Comments:

IV - Disclaimer

I certify that the answers given herein are true and complete to the best of my knowledge (Please check this box to certify all information).
 
PLEASE READ AND ACKNOWLEDGE:

THIS FORM WILL BE USED WHEN VERIFYING EMPLOYMENT. A JOB OFFER MAY NOT BE EXTENDED UNTIL WORK AND/OR EDUCATION INFORMATION IS VERIFIED.
By checking this box I authorize the referred to person(s) named, or past employees of named employers to give any pertinent information regarding my employment or education, together with any information they may have regarding me whether or not it is on their records. I hereby release said employers or persons from all liability for any damages whatsoever for issuing this information.
© 2006 MED-TECH Resource, Inc.