Onsite Medical Service, Inc Employment Application

Growing company located in the west metro area is looking for Technicians to perform on-site hearing tests in Minnesota, Wisconsin, & occasionally North & South Dakota.

Step 1 of 4

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Position You're Applying For(Required)

How were you referred to us:(Required)

Today's Date(Required)

MM slash DD slash YYYY

Your Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Your Phone(Required)

Date Available(Required)

MM slash DD slash YYYY

Best Time To Call You

When is the best time for us to reach you via telephone?

Pay Expected(Required)

If you are under 18 years of age, can you provide a work permit?(Required)

Yes

If no, please explain:(Required)

Previously Employed by Onsite Medical Service, Inc?(Required)

Yes

If yes, name and dates worked:(Required)

Are you legally eligible to work In U.S.?(Required)

Yes

Available(Required)

Full-Time

Part-Time

Have you every pleaded guilty, no contest or been convicted of a crime?(Required)

Answering yes to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Yes

If yes, give dates and details:(Required)

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Driver’s License Number

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Driver's License State

High School

Name of School City, State(Required)

Did you graduate?(Required)

Yes

College

Name of School City, State

Years Attended

Diploma, Degree, or Certificate Received?

Course of Study

Did you graduate?

Yes

Other (Specify)

Name of School City, State

Diploma, Degree, or Certificate Received?

Course of Study

Did you graduate?

Yes

Summarize Your Special Skills or Qualifications:(Required)

Previous Employment (begin with most recent position)

Most Recent Employer:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Held:

Dates From:

MM slash DD slash YYYY

Dates From:

MM slash DD slash YYYY

Full-Time or Part-Time Position?

Full-Time

Part-Time

May we contact employer?

Yes

Reason for Separation

Supervisor’s Name:

Phone

Starting Pay: $

Hourly

Annually

Other

Starting Pay Amount

Ending Pay: $

Hourly

Annually

Other

Ending Pay Amount

Duties/Responsibilities:

Employer:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Held:

Dates From:

MM slash DD slash YYYY

Dates To:

MM slash DD slash YYYY

Full-Time or Part-Time Position?

Full-Time

Part-Time

May we contact employer?

Yes

Reason for Separation

Supervisor’s Name:

Phone

Starting Pay: $

Hourly

Annually

Other

Starting Pay Amount

Ending Pay: $

Hourly

Annually

Other

Ending Pay Amount

Duties/Responsibilities:

Employer:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Held:

Dates From:

MM slash DD slash YYYY

Dates To:

MM slash DD slash YYYY

Full-Time or Part-Time Position?

Full-Time

Part-Time

May we contact employer?

Yes

Reason for Separation

Supervisor’s Name:

Phone

Starting Pay: $

Hourly

Annually

Other

Starting Pay Amount

Ending Pay: $

Hourly

Annually

Other

Ending Pay Amount

Duties/Responsibilities:

By submitting my application, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period oi time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use uf disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Name

First Last

List three references (other than relatives) that have knowledge of your work experience and abilities:

Name of 1st Reference(Required)

First Last

Phone(Required)

Name of 2nd Reference(Required)

First Last

Phone(Required)

Name of 3rd Reference(Required)

First Last

Phone(Required)

Do you currently have relatives or friends working for Onsite Medical Service, Inc?(Required)

Yes

If yes, Relationship:

Would you agree to pre - hiring and random drug testing?(Required)

Yes

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