Jobs

Date

Your name (Last, First MI)

Address (Street)

Address (City)

Address (State)

Address (Zip)

Home number

Mobile number

Your email

DRIVERS LICENSE INFORMATION

Drivers license number

Expiration date

State where issued

Are you over 18 years of age?
YesNo

What prompted your application to Tech Medical?

Are you eligible to work in the United States?
YesNo

If not a U.S. citizen please indicate type of visa

Tech Medical Inc. may require overtime as determined by the department. Do you have any objection to meeting this requirement?
YesNo

Do you have any physical limitations or handicaps that would prevent you from properly performing the work required in this job?

Have you ever been convicted of a crime (felony, misdemeanor, DUI, etc)?
YesNo

If you answered yes to the question above please explain

POSITION

Position desired/applying for

Pay desired

Date available

Preferred work status
Full-timePart-time

Work schedule preferred (check all that apply)
DaysEveningsNightsAny shift

Do you have any relatives that work at Tech Medical?
YesNo

If you answered yes to the above question, please complete below

Have you ever applied or been employed at Tech Medial Inc.?
YesNo

If you answered yes to the above question, please complete below

EDUCATION AND TRAINING

Check last grade completed
High school 9High school 10High school 11High school 12College/Tech 1College/Tech 2College/Tech 3College/Tech 4Graduate 1Graduate 2Graduate 3Graduate 4

Complete institution information

Complete license/registration/certification information

Has your license, registration, or certification ever been suspended, or have you ever been placed on probationary status regarding the same?
YesNo

If you answered yes to the above question, please explain

Have you ever been barred from participating in a Federal Funded program?
YesNo

If you answered yes to the above question, are you currently still barred from participation?
YesNoNot applicable

SKILLS INFORMATION

Computer and/or Software Skills Information (check all that apply)
ExcelPower PointTypingOasisAxxessEpic

Typing: Words per minute

May we contact your present employer?
YesNo

PREVIOUS EMPLOYEMENT

EMPLOYER #1

Employer

Job title

Address (Street)

Address (City)

Address (State)

Address (Zip)

Supervisor

Date worked from

Date worked to

Brief description of duties

Reason for leaving

Account for period between jobs

EMPLOYER #2

Employer

Job title

Address (Street)

Address (City)

Address (State)

Address (Zip)

Supervisor

Date worked from

Date worked to

Brief description of duties

Reason for leaving

Account for period between jobs

EMPLOYER #3

Employer

Job title

Address (Street)

Address (City)

Address (State)

Address (Zip)

Supervisor

Date worked from

Date worked to

Brief description of duties

Reason for leaving

Account for period between jobs

EMPLOYMENT REFERENCES

Please list three (3) references whom we can contat, other than relatives, who know your qualifications and work history.

REFERENCE #1

Name

Title

Employer

Address (Street)

Address (City)

Address (State)

Address (Zip)

Email

Phone number

REFERENCE #2

Name

Title

Employer

Address (Street)

Address (City)

Address (State)

Address (Zip)

Email

Phone number

REFERENCE #3

Name

Title

Employer

Address (Street)

Address (City)

Address (State)

Address (Zip)

Email

Phone number

MILITARY SERVICE

Branch

Date from

Date to

Rank at discharge

Your most important duties and training during service

Tech Medical considers all applicants for all positions without regard to race, color, religion, creed, national origin, age, disability, marital or veteran status, sex or any other legally protected status.

APPLICANT CERTIFICATION AND ACKNOWLEDGMENT:

I certify that my statements in this application are true and correct to the best of my knowledge. I understand that any misstatement I have made may subject me to discharge if I am hired. I authorize Tech Medical to make inquiries concerning my previous employment and the information I have provided in this application, and in the event of my employment by Tech Medical to provide any of my subsequent employers with information concerning my employment with Tech Medical. I hereby release Tech Medical and all its employees from any liability on account of or arising out of the exchange of such information. I understand that as a condition of my employment, Tech Medical my require overtime to be worked in excess of the regular scheduled work day and/or work week. I agree that my continued employment if I am hired by Tech Medical, is contingent upon passing a drug screening, background check and physical examinations, when requested, in order to verify my continued capability to properly perform my job and upon my compliance with the company's policies and procedures.

I have also read and agree to your Terms of Use and Privacy Policy.

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