Candidate Application and Background check sheet
- 1. -- Last Name First Name Middle Name Today's Date MedSearch Corp. Medical Placement Service Since 1936! Southdale Medical Center Suite 177 · 6545 France Avenue South. Edina, Minnesota 55435 Phone: 952/926-6584 · TollFree 1-800-458-4965 · Fax: 952/926-7584 MedSearch Corp. is an Equal Opportunity Search Firm Instructions: 1. Please print. 2. Please inform us if assistance/accommodation is needed in completing the application, or during any part of the application process. 3. Please do not use resume in place of information on application. 4. Include any relevant military experience and unpaid work experience, if any. 5. Please make sure to read and sign page 4. Employment Application PERSONAL INFORMATION Last Name First Name Middle Name Social Security Number Street Address Apt. # Home Phone with Area Code City County State Zip Office Phone with Area Code Message Phone with Area Code o Full-time Schedule Preference o Part-time o Days o Nights Hours per week o Evenings o Weekends Position Desired Date Available Salary Desired First Choice Name and location of college or university egree Received? Indicate Degree: Courses/Major Honors Name and location of college or university egree Received? 0 Yes 0 No I GPA I Courses/Major Indicate Degree: Honors BusinessfTechnicalNocational/Correspondence, etc. Certificate/degree or # of credits Subject Describe any other specialized training or qualifications relating to this position (such as seminars. military. professional affiliations. certificates, awards. internships, externships)
- 2. EDUCATION continued ,~'., 't Professional licenses/certificates/registrations (include numbers) Expiration date: Expirationdate: Expiration date: BUSINESS SKILLS :., rw . List professional, technical or clerical skills that you would bring to the position for which you are applying (e.g., accounting, computer hardware, software, programming languages, etc.): List office equipment you can operate (e.g., calculator, word processor, personal computer, etc.): BUSINESS REFERENCES Please list business or work related references and their relationship to you Name Business Relationship Area CodefTelephone Number 1. 2. 3. 2 EMPLOYMENT HISTORY '... 1. Dates of employment (current or most recent position) Title of position From Mo./Yr. To Mo./Yr. Name of employing firm Type of business Area Code/Phone Address May we contact for DYes o No o Full-time o Part-timereference? City State Zip Salary: Starting $ Rnal$ Supervisor (Name and Area CodelPhone Number) Base Pay Incentives $ $ Description of duties performed, skills, accomplishments Reason for leaving 2. Dates of employment Title of position From Mo./Yr. ToMo./Yr. Name of employing firm Type of business Area Code/Phone Address May we contact for DYes o No o Full-time o Part-timereference? City State Zip Salary: Starting $ Final $ Supervisor (Name and Area Code/Phone Number) Base Pay Incentives $ $ Description of duties performed, skills, accomplishments Reason for leaving
- 3. ---- 3 3. Dates of employment Title of position From Mo.tYr. ToMo.tYr. Name of employing firm Type of business Area Code/Phone Address May we contact for DYes o No o Full-time o Part-timereference? City State Zip Salary: Starting $ Final $ Supervisor (Name and Area Code/Phone Number) Base Pay Incentives $ $ Description of duties performed. skills. accomplishments Reason for leaving 4. Dates of employment Title of position From Mo.tYr. ToMo.tYr. Name of employing firm Type of business Area Code/Phone Address May we contact for reference? DYes o No o Full-time o Part-time City State Zip Salary: Starting $ Final $ Supervisor (Name and Area Code/Phone Number) Base Pay Incentives $ $ Description of duties performed. skills, accomplishments Reason for leaving 5. Dates of employment Title of position From Mo.tYr. To Mo.tYr. Name of employing firm Type of business Area Code/Phone Address May we contact for DYes o No o Full-time o Part-timereference? City State Zip Salary: Starting $ Final $ Supervisor (Name and Area Code/Phone Number) Base Pay Incentives $ $ Description of duties performed. skills. accomplishments Reason for leaving If you have been unemployed for a period of three consecutive months or more within the past seven years, please provide the dates of unemployment and an explanation below: List any professional activities, experiences. achievements, or other special skills not mentioned elsewhere that relate to the position(s) for which you are applying:
- 4. ---- LEGAL CONTRACT. READ AND UNDERSTAND ALL AGREEMENTSAND CONTRACTSARE SUBJECTTO THE RULESOF THE DEPARTMENTOF LABOR & INDUSTRYAND THE LAWSOF THE STATEOF MINNESOTA. In no instance will any individual candidate who is identified, appraised or recommended by MedSearch Corp. for employ- ment become liable in whole or in part to pay a fee of any kind, directly or indirectly, on account of any service performed by MedSearch Corp. All information given to me by MedSearch Corp. is to be held confidential and is given to me only for my exclusive use and benefit. I agree to notify MedSearch Corp. promptly upon the acceptance of a position and report the results of all interviews. I HAVE READ AND UNDERSTAND THE ABOVE CONTRACT. I HAVE DISCUSSED THIS CONTRACT WITH A REPRESENTATIVE OF THE AGENCY AND HAVE RECEIVED A DUPLICATE. Dated Accepted Consultant Signature of Applicant AUTHORIZATION AND ACKNOWLEDGMENT MedSearch Corp. is committed to equal employment opportunity for all applicants without regard to race, color, creed, religion, gender, age, marital status, national origin, disability, sexual orientation, or any other characteristic protected under federal, state, or local law. I hereby acknowledge the filing of my employment application with MedSearch Corp. to assist me in securing employment. The information I have provided in this application (including all attachments) is true and correct. I authorize MedSearch Corp. to conduct an inquiry into the information contained in this application. I authorize my current and former employers, educational institutions, and all licensing, registering and certifying organizations to provide information about me. I hereby release all employers, educational institutions, and other individuals or entities which may provide information about me in connection with this application from all liability for issuing such information. I further understand that this information will be shared with all appropriate employers who have listed job openings with MedSearch Corp. I hereby waive any privilege I may have to such information. I also understand that my employment is conditioned upon acceptable references and background checks (for certain positions, employment is also conditioned upon drug testing). I hereby acknowledge that I have read and received a copy of this statement. Today's DateSignature of Applicant CONSULTANT'S NOTES 4
- 5. LEGAL CONTRACT. READ AND UNDERSTAND ALL AGREEMENTSAND CONTRACTSARE SUBJECTTO THE RULESOF THE DEPARTMENTOF LABOR & INDUSTRYAND THE LAWSOF THE STATEOF MINNESOTA. In no instance will any individual candidate who is identified, appraised or recommended by MedSearch Corp. for employ- ment become liable in whole or in part to pay a fee of any kind, directly or indirectly, on account of any service performed by MedSearch Corp. All information given to me by MedSearch Corp. is to be held confidential and is given to me only for my exclusive use and benefit. I agree to notify MedSearch Corp. promptly upon the acceptance of a position and report the results of all interviews. I HAVE READ AND UNDERSTAND THE ABOVE CONTRACT. I HAVE DISCUSSED THIS CONTRACT WITH A REPRESENTATIVE OF THE AGENCY AND HAVE RECEIVED A DUPLICATE. Dated Accepted Consultant Signature of Applicant AUTHORIZATION AND ACKNOWLEDGMENT MedSearch Corp. is committed to equal employment opportunity for all applicants without regard to race, color, creed, religion, gender, age, marital status, national origin, disability, sexual orientation, or any other characteristic protected under federal, state, or local law. I hereby acknowledge the filing of my employment application with MedSearch Corp. to assist me in securing employment. The information I have provided in this application (including all attachments) is true and correct. I authorize MedSearch Corp. to conduct an inquiry into the information contained in this application. I authorize my current and former employers, educational institutions,and all licensing, registering and certifying organizations to provide information about me. I hereby release all employers, educational institutions, and other individuals or entities which may provide information about me in connection with this application from all liability for issuing such information. I further understand that this information will be shared with all appropriate employers who have listed job openings with MedSearch Corp. I hereby waive any privilege I may have to such information. I also understand that my employment is conditioned upon acceptable references and background checks (for certain positions, employment is also conditioned upon drug testing). I hereby acknowledge that I have read and received a copy of this statement. Signature of Applicant Today's Date CONSULTANT'S NOTES 4
- 6. --- -- - - -- Disclosure and Authority to Release Information I understand that in processing my application with MedSearch Corp, an investigative consumer report may be conducted. FCRA § 606. (a) (1) disclosure requirements; Any such background check report may contain information bearing on my character, general reputation, personal characteristics, mode of living and credit standing. Information may include, but is not limited to; employment history, education, criminal records, credit history, motor vehicle records, personal references, and any data provided on this application, or during the interview process. If currently employed: My current employer may be contacted 0 Yes o No I authorize the appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquiries or disclosures. I further understand and waive my right of privacy in this investigation and release and hold harmless MedSearch Corp, and its agent Verified Credentials, Inc., from any liability. An investigative consumer report may be generated summarizing this information. I have a right under the "Fair Credit Reporting Act" and state law to obtain a copy of this report by providing proper identification and directing a written request to Verified Credentials, Inc., 20890 Kenbridge Court, Lakeville, MN 55044. 1-800-473-4934. If employed in CA, MN, or OK; I would like a copy of my report. 0 Yes o No I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, and I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may be cause for rejection or termination of my employment or application. Legal Last Name Legal First Name Legal Middle Name Street Address City State Zip Code Please list any additional addresses you have lived, worked and attended schools in during the past 7 years: City State City State City State City State Other Name(s) Used and Date(s) Changed: DriversLicenseNumber State Issued ExpirationDate Dateof Birth (To be usedfor BackgroundInformationIDonly) I AUTHORIZEA PHOTOCOPYOFTHIS RELEASETO BEACCEPTEDWITHTHE SAMEAUTHORITYAS THE ORIGINALAND IF EMPLOYEDBYTHE ABOVENAMEDCOMPANYTHIS RELEASEWILLREMAININ EFFECT THROUGHOUTSUCHEMPLOYMENT. Signature Social Security Number Date