PROMEDICAL - Employment Application Form

Employment Application

Please complete the form below to apply for a position with PROMEDICAL.
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email Address*
example@example.com
Mobile Phone Number*
Position you are applying for:
How did you hear about us:
Name of Current Employee
Recruiter Name
Available Start Date

MonthDayYear
Date

Background Questions
1. Are you a citizen of the United States?*

YesNo
Are you authorized to work in the United States?

YesNo
2. Have you previously worked for PROMEDICAL?*

YesNo
When were you previously employed by PROMEDICAL?
Enter years of service
3. Have you ever filed an application for employment with us before?*
Date of your previous application to PROMEDICAL:
4. Are you currently employed?*
5. Are you currently on layoff status and subject to recall?*
6. Are you able and willing to travel for this job if travel is necessary?*
7. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
If yes, please explain and describe what accommodations might be necessary:
Accommodations that might be necessary
8. Have you ever been convicted of a felony?*

YesNo

Education
High School*
Name of Employer
Year of Graduation
Location
City, State
College
Name of College or University
Years of Attended
Enter date range
Location
City, State
Degree Completed
Graduate School
Name of College or University
Years of Attended
Enter date range
Location
City, State
Degree Completed
Other Relevant Coursework
Name of Educational / Training Facility
Years of Attended
Enter date range
Location
City, State
Coursework Completed

Employment History

Start with your current or most recent employer and work backwards regarding all former employers.
1. Current or Most Recent Employer:*
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of Employment

Start Date of EmploymentEnd Date (if not Currently Employed)
Job Responsibilities
Hours per week
Reason for Leaving
May we Contact this Employer?*
2. Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of Employment

Start Date of EmploymentEnd Date of Employment
Job Responsibilities
Hours per week
Reason for Leaving
May we Contact this Employer?
3. Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of Employment

Start Date of EmploymentEnd Date of Employment
Job Responsibilities
Hours per week
Reason for Leaving
May we Contact this Employer?
4. Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of Employment

Start Date of EmploymentEnd Date of Employment
Job Responsibilities
Hours per week
Reason for Leaving
May we Contact this Employer?

References

Please list two references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*
Years Known:*
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2
Name:*

First NameLast Name
Phone Number*
Years Known:*
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Disclosure & Background Check Authorization Form
Pursuant to the federal Fair Credit Reporting Act, I hereby authorize ProMedical, LLC and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic citations and registration; and any other public records.
I, {fullName}, authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish [Company Name] or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.
I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be provided to me.
Other Names Used
Social Security Number*
Driver's License Number
Signature*

Disclaimer & Submission
I certify that my answers above are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature*
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Employment Application

Background Questions

Education

Employment History

References

Reference 1

Reference 2

Disclosure & Background Check Authorization Form

Disclaimer & Submission