Employment with MedServices Step 1 of 7 - Personal Info 14% I. Identifying DataName* First Middle Last Date of Birth* Are you a US Citizen?*Select...YesNoAre you authorized to work in the US?*N/AYesNoHave you been previously employed by MedSevices?*Select...YesNoUnder what name were you employed?*Conviction Record A conviction record will not necessarily be a bar to employment. Factors such as age and time of the offense, seriousness, nature of the violation and the applicant’s rehabilitation will be considered in the hiring process.Have you been convicted of a felony?*Select...YesNoPlease provide details: Date, location, nature, and final outcome*Current ResidencePresent Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Years at this Address* II. Contact DataHome Phone*Cell PhoneWork PhoneEmail* Preferred Method of ContactHome PhoneCell Phone (Call)Cell Phone (Text)Work PhoneEmailEmergency ContactEmergency Contact Name*Emergency Contact Address / Location*Emergency Contact Phone* III. PreferencesPosition Applying For*Date Available* Desired Hourly Rate of Pay*Minimum and Maximum Number of Hours Available*Please tell us about any specific limitations to your availability.If referred by someone, Please Enter Their Name IV. Education HistoryPlease list institution name, location, year of completion, degree obtained and any additional details. Put NONE, if a section does not apply.Highest Level of Education Completed High School College Trade School or Other School High School*College*Certificate Programs* VI. Employment HistoryPlease list your current and most recent employer.Current or Most Recent EmployerCompany NameAddress or Location*Supervisor Name*Phone*Date(s) of Employ*May We Call Your Supervisor for a Reference?*Select...YesNoPrevious EmployerCompany Name*Address or Location*Supervisor Name*Phone*Date(s) of Employ*May We Call Your Supervisor for a Reference?*Select...YesNo VII. Agreement & SignatureRead Carefully Before Signing*In signing and submitting this application for employment, I clearly understand and agree: 1. That the information contained in this application is complete and true in all respects. I understand that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time, and it will be grounds for refusal to employ me. 2. That the references provided in my resume, schools and past employers listed above may release any and all information concerning my previous employment and any information they may have, personal or otherwise pertaining to my work record, my work habits, and my work performance, and I release all parties, including MEDSERVICES from all liability for any damage or claim that may result from furnishing the information. 3. That any employee handbook which I may receive will not constitute an employee contract, but will be merely a statement of MEDSERVICES’s current policies, which are subject to change without prior notice. 4. MEDSERVICES reserves the right to require its employees to submit to blood test, urinalysis, or other tests for the presence of alcohol or drugs. I understand that refusal to submit to any of these tests or other test or to a search by MEDSERVICES or its clients, when requested to do so, will result in termination of my employment. 5. MEDSERVICES reserves the right to complete a criminal background check on all potential new hires and randomly throughout employment of all employees. 6. Failure to comply with HIPAA and Confidentiality practices of MEDSERVICES or its clients will result in termination of my employment. 7. I understand and agree that if I am offered employment by MEDSERVICES my employment will be for no definite term and that either MEDSERVICES or I will have the right to terminate the employment relationship at any time, with or without cause and with or without notice. I also agree to conform to MEDSERVICES rules and regulations. I also understand that this status can only be altered by a written contract of employment, which is specific as to all material terms and is signed by a MEDSERVICES owner.Select...I AgreeI DO NOT AgreeSignatureApplication Date* VIII. ResumeYour resume is required.Upload Your ResumeAccepted file types: pdf, doc.PhoneThis field is for validation purposes and should be left unchanged.