Employment Application


APPLICATION FOR EMPLOYMENT

 

PERSONAL DATA

Last Name First Name Middle Name Today's Date
01-01-1970

Address

Email:

Home Phone Business Phone Other

Did an employee of HME Specialists refer you?:

If yes, please provide employee's name:

Are you at least 18 years of age?:

Are any employees of HME Specialists related to you by blood or marriage?:

If yes, please give name and relationship:

NOTE: It is the policy of HME Specialists to prohibit the hiring of relatives in full-time positions.

Do any of your immediate family members work for a competitor of HME Specialists?:

Do you have the legal right to work in the United States?:

What languages do you speak?:

List, by title the position for which you wish to apply:

# of hours applying for:

# of hours per week:

If the position you are applying for requires you to be on-call, can you work nights, weekends and holidays as necessary?:

 

Education

Type of School Name and Address From To Grad? Degree Major
High School (GED)
College Undergrad
College Graduate
Vocational Business
Military Schools

LICENSES & SPECIAL SKILLS

Number Expiration Date State of Issuance
01-01-1970

List any laboratory, medical or shop equipment you operate:

Do you have any lifting limitations?:

Do you type?:

WPM:

List any office equipment you operate:

List any Word-processing/ Computer software programs with which you are proficient:

 

EMPLOYMENT HISTORY

Begin with your PRESENT or MOST RECENT employer. Please list in order all employment.

Your name if different from present name:

Name of Employer Start Date End Date
01-01-1970 01-01-1970
Address of Employer Starting Salary $ Ending Salary $
 

Job Title:

Supervisor Name and Title:

Specific Duties:

Reason for Leaving:



Name of Employer Start Date End Date
01-01-1970 01-01-1970
Address of Employer Starting Salary $ Ending Salary $

Job Title:

Supervisor Name and Title:

Specific Duties:

Reason for Leaving:


Your name if different from present name:


Name of Employer Start Date End Date
01-01-1970 01-01-1970
Address of Employer Starting Salary $ Ending Salary $

Job Title:

Supervisor Name and Title:

Specific Duties:

Reason for Leaving:

Section Buttons:

Can we contact your current employer?:

MILITARY HISTORY (OPTIONAL)

Your name if different from present name:

01-01-1970 01-01-1970
01-01-1970 01-01-1970

Rank Attained:

Job Title:

Briefly describe your specific duties:

Have you ever been excluded, debarred, suspended or sanctioned from participating in any Federal or State health care related programs? Are you able to perform the essential functions of the position(s) for which you have applied, with or without accommodation?
 

Please list 3 professional references. Include name, professional relationship and phone number

Name Professional Relationship Phone

NOTE: HME's policy could disqualify an applicant who has a certain criminal history from employment in particular positions. All positions are contingent on background and drug test.

Permission is hereby granted to HME Specialists to conduct any necessary and reasonable investigation with respect to statements and other information in this application. I release HME Specialists, my former employers and personal references from any liability for damage caused by giving and receiving information or opinions as to my employment and character. I agree to furnish any other information required of me related to my employment. I also understand and agree that any false statements or any material misrepresentation of the information referred to above will be sufficient grounds for my separation. I understand the requirements and essential functions of the job(s) and certify that I am able to perform those job duties and functions. I have a genuine interest to be employed and no other purpose in submitting this application. I understand that this employment application will remain active for 120 calendar days, and that upon expiration of this application, to continue to be considered for employment, I must complete a new application.

 

Leave this empty:

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Document name: Employment Application
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Timestamp Audit
December 10, 2020 1:23 pm MSTEmployment Application Uploaded by Michael Dumont - mdumont@clearsky.systems IP 81.155.105.144
December 16, 2020 9:55 am MSTSammi Reynolds - clearsky.mrd@gmail.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:02 am MSTSammi Reynolds - clearsky1066@outlook.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:02 am MSTMike monitor - michael@lokacreative.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:18 am MSTSammi Reynolds - clearsky1066@outlook.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:18 am MSTMike monitor - michael@lokacreative.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:22 am MSTSammi Reynolds - clearsky1066@outlook.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:22 am MSTMike monitor - michael@lokacreative.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:25 am MSTSammi Reynolds - sreynolds@hmespecialists.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:25 am MSTResumes Archive - resumes@hmespecialists.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 16, 2020 10:39 am MSTResumes Archive - resumes@hmespecialists.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 17, 2020 3:56 am MSTResumes Archive - resumes@hmespecialists.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64
December 17, 2020 3:56 am MSTSammi Reynolds - sreynolds@hmespecialists.com added by Michael Dumont - mdumont@clearsky.systems as a CC'd Recipient Ip: 86.174.102.64