Employment Application

Fields marked with an asterisk (*) are required.


YesNo


YesNo


YesNo


Full-timePart-time

Day Mon Tue Wed Thu Fri Sat Sun
AM Y Y Y Y Y Y Y
PM Y Y Y Y Y Y Y

Name of School Years Attended Highest Degree Earned

Company Name Job Title Time Employed May we Contact? Supervisor Name and Number
Yes
Yes
Yes

Name Phone Number Years Known Relationship

Attach any other documents such as resumes, cover letters and additional references below.

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee an employment opportunity. I further understand that, should an offer of employment be extended by Medzen Services Inc. (hereinafter referred to as MSI) that such employment with MSI is at-will, with no specified duration and may be terminated by either MSI or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of MSI or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of MSI except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President of MSI.

In consideration for employment with MSI if employed, I agree to conform to the rules, regulations, policies and procedures of MSI at all times and understand that such obedience is a condition of employment. I understand that due to the nature of MSI business, attendance and punctuality are considered essential requirements of every job at MSI and that poor attendance or tardiness will result in disciplinary action including but not limited to termination.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to MSI and/or any of its representatives, agents or vendors.

I hereby authorize MSI to pull any investigative consumer report from a reporting agency for the purpose of evaluating employment history. This report may contain information regarding my past education, past employment, general reputation, and criminal record from record sources. I understand that I have a right to request additional disclosures regarding the nature and scope of the investigation.

I understand that this application is considered current for one year (twelve months). If I wish to be considered for employment after this period, I must fill out and submit a new application.