IPD Employment Application Form V4

Upon Employment, can you show verification of your legal right to work in the United States?*

YesNo
Are you at least 18 years old?*

YesNo

Education Information*

	School Name	City & State	Major Course of Study	Highest Grade Completed (Diploma/Degree)
High School
College
Technical or Trade School
Post-Graduate

Activities, Honors, Offices held that are job related
omit those which indicate race religion national origin color sex age or disability
Describe other job-related training completed
omit those which indicate race religion national origin color sex age or disability

EMPLOYEMENT HISTORY: Put N/A if no employment history *

	Employer (begin with most recent)	Dates of Employment	Reason for Change	Salary
1
2
3
4

REFERENCES: Please list three (3) references that are familiar with your work life*

I would say that I use Microsoft Office (Word, Excel, and Outlook):*

Never UsedSomewhat UseFrequently Use
How do you feel about public speaking?*

Very ComfortableSomewhat ComfortableSomewhat UncomfortableVery Uncomfortable
Select the box to confirm that you understand the following:

I understand that this is not a work from home jobI understand that the IPD Sales Rep position hours are from 10am to 7pm

Background Authorization Form
Name*
Middle Name *
Enter N/A if no Middle Name
Last Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Driver's License Number*
State Issued*
Position Applied For*
Applicant Signature*

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Date*

MonthDayYear
Date
I have read and understand this Background Disclosure and Authorization Form:*
Initials

DRUG TESTING CONSENT

Please provide the following to apply for employment:
As a condition for my application being considered, I understand and agree to undergo substance screening if requested. I understand that if tested and results are positive, I shall not be considered further by the company.

I hereby authorize any physician, laboratory, hospital or medical professional retained by the company to conduct such screening and to provide the results to the company, and release the company and any person affiliated with the company and any such institution or person conducting the screening from any liability.
PERSONAL INFORMATION:
Name*

First NameLast Name
Birth Date MM/DD/YYYY*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Drivers License Number*
State Issued*
PLEASE READ AND SIGN BELOW:
All statements and information given in this application are true to the best of my knowledge and belief. Failure to provide truthful responses may prejudice my rights to Worker's Compensation benefits pursuant to State Statues.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

	Yes	No	Details
Back Injury
Herniated Intervertebral disc in your back
Back Surgery for removal of disc
Neck Injury
A herniated disc in your neck
Neck Surgery for removal of disc
Knee Injury
Surgery on either of your knees
Shoulder Injury
Surgery on either Shoulder
Elbow Injury
Surgery on either elbow
Wrist Injury
Surgery on either wrist
Rupture (hernia)? Indicate if surgery:
Arthritis or rheumatism
Amputation of food, leg, arm, finger, etc.
Epilepsy
Diabetes
Cardiac Disease (including High Blood Pressure)
Respiratory Problems
Total loss of sight in one or both eyes
Partial loss of corrected vision (of more than 75% bilaterally)
Residual disability from Poliomyelitis
Cerebral Palsy
Multiple Sclerosis
Parkinson's Disease
A vascular Disorder
Hospitalization for any mental disability(6 months or more)
Hemophilia
Chronic Osteomyelitis
Surgical or spontaneous fusion of a major weight bearing joint
Muscular Dystrophy
DVT - Deep Vein Thrombosis
Total deafness
Allergies to products containing latex
Other: Allergies or Asthma
Injury, surgery or disability not listed

EMPLOYMENT APPLICATION