We consider all applicants for all positions without regard to race, color, religion, creed, gender, national origin, disability or age.

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Employment History

Starting with your most recent employer, provide the following information.

Most Recent Employer

Month Year to Month Year
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2nd Most Recent Employer

Most Recent Employer

 
 


 

3rd Most Recent Employer


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Skills and Qualifications



 

Educational Background

Starting with your most recent school attended, provide the following information

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References

List names and telephone numbers of two business/work references who are not related to you and are not previous supervisors and one personal reference who is not related to you.


 

 

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
 

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
 
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating an applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
 
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice , and the employer reserves the same right to terminate my employment for any lawful reason with or without cause and with or without prior notice. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language and valid unless they are in writing and signed by the employer’s president.
 
I understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
 
Med A Quest will request a background check, containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable).
 
A third party company will prepare or assemble the background report for Med A Quest. The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verifications; address and alias history; credit history; verifications of your educations, employment and earnings history; professional licensing; credential and certification checks; drug/alcohol testing results and history; military service; and other information. I hereby authorize Med A Quest to obtain the consumer reports described.
 
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to eliminate me from further consideration for employment, or may result in my immediate discharge from the employer’s service, whenever it is discovered.
 
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. I understand that by entering my name below, this will act as my signature on this document.