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Medical Equipment Customer Service Representative Employment Form
Please allow yourself time to complete this form. This form is 6 pages and will ask for education background, work experience, and references. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered. The company requests three (3) days advance notice for any accommodations necessary to complete the application process. The company will make every reasonable effort to provide an effective accommodation, if feasible.
Personal Information
Name
*
First Name
Last Name
Date
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Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
List all names you have used in the past
Are you legally authorized to work in the U.S. for any employer?
*
Yes
No
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Hawthorne Pharmacy and Medical Equipment
Are you seeking (check all that apply)
*
Full-time
Part-time
Temporary
Summer Employment
Other
If you chose "other," please explain
Salary desired
If the position requires any of the following, are you available and willing too:
Yes
No
Travel for work
Work overtime
Relocate
Do you have any friends or relatives working for Hawthorne Pharmacy?
Yes
No
If yes, whom?
Have you ever applied and/or worked for our company?
Yes
No
If yes, please state the date, location and position for which you applied and/or worked.
How did you learn about Hawthorne Pharmacy and/or the position?
Are you currently or do you expect to be engaged in any other business or employment?
Yes
No
Can you meet the attendance requirements of the position you are applying for?
Yes
No
Are there any days or hours you would be unable or unwilling to work?
Yes
No
If yes, please specify those days and/or hours
Can you perform the essential functions of this position, with or without reasonable accommodations?
Yes
No
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Education
High School
College
Graduate School
Use the space below to describe why you are interested in working for our company. List the skills and abilities which you feel particularly qualify you for a position with us.
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Work History
List names of employers in consecutive order with present or most recent employer first. Account for all periods of time including military service and any periods of unemployment. If self-employed, provide company name and supply business references. Please provide the month and year for all dates, and do not reference your résumé.
Employer 1
May we contact this employer?
Yes
No
Employer 2
May we contact this employer?
Yes
No
Employer 3
May we contact this employer?
Yes
No
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References
Reference 1
Reference 2
Reference 3
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Please read carefully, initial each paragraph and sign at the bottom of the page.
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
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Initial
I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, I authorize the references I have listed to disclose to the Company all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
*
Initial
I understand that nothing contained in the application, or conveyed during any interview which may be granted, or during my employment, if hired, is intended to create an employment contract between the Company and me. In addition, I understand and agree that if I am employed, my employment is at will and is for no definite or determinable period and may be terminated at any time, with our without prior notice, or with or without cause, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s president and/or owner.
*
Initial
I understand that in connection with my application for employment, the Company may obtain a consumer report and/or investigate consumer reports about me that may contain information as to my character, general reputation, personal characteristics, and mode of living. Such reports may include or consist of my driving history obtained from the Department of Motor Vehicles. I further understand that any job offer extended by the Company is contingent upon receipt of a favorable consumer or investigative consumer report about me.
*
Initial
I understand that in connection with my application for employment, depending upon the position for which I have applied, any offer of employment is conditioned upon my taking and passing a post-offer/pre-employment drug test, when given pursuant to company policy, and if necessary for the position for which I have applied, a post-offer/pre-employment medical examination. I understand that I may refuse to take any required pre-employment drug test and/or medical examination, but that if I do, any offer of employment will be immediately withdrawn.
*
Initial
I HAVE READ THE ABOVE PARAGRAPHS, UNDERSTAND THEIR IMPORTANCE AND EFFECT UPON MY EMPLOYMENT, AND ACCEPT SAME AS CONDITIONS OF MY EMPLOYMENT WITH COMPANY.
Initial
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This application, when completed and signed, becomes the property of the Company.
Applicant Electronic Signature
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Date
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Month
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Date Signed
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