APPLICATION FOR EMPLOYMENT

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law.

PERSONAL INFORMATION
Date:	Email Address:
Name: Last, First Middle
Address: Street Address City, State, Zip Code
Home Phone:	Cell Phone:

EDUCATION
School Name	Location City, State	Years Attended	Degree Obtained	Major
High School
College University
Trade School

Please list all professional, trade, business or civic organizations to which you belong: (You may exclude groups which indicate race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Are you currently authorized to work in the United States on a full-time basis?

YES NO

Will you now, or will you in the future, require sponsorship for employment visa status (e.g. H-1B status, etc.) to work legally for our Company in the United States?

YES NO

Are you 18 years of age or older?	Are you currently a student?

YES NO	YES NO

Are you presently employed?	If so, may we contact your present employer?

YES NO	YES NO

Are you on a lay-off and subject to recall?

YES NO

EMPLOYMENT EXPERIENCE/HISTORY
Please list each job/position held. Start with your present or most recent job/position. Include military service assignments, including the particular branch you have served in, and volunteer activities. (You may exclude groups which indicate race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law). NOTE: a dishonorable or general discharge from military service is not an absolute bar to employment, and other factors will affect a final hiring decision.
Employer Name:	Start Date: End Date:
Address: Street, City, State	Job Title:
Reason for Leaving: Brief Explanation.	Duties Performed:
Supervisor’s Name:	Supervisor’s Number:
Employer Name:	Start Date: End Date:
Address: Street, City, State	Job Title:
Reason for Leaving: Brief Explanation	Duties Performed:
Supervisor’s Name:	Supervisor’s Number:
Employer Name:	Start Date: End Date:
Address: Street, City, State	Job Title:
Reason for Leaving: Brief Explanation.	Duties Performed:
Supervisor’s Name:	Supervisor’s Number:

PROFESSIONAL REFERENCES
Name	Title	Company	Phone

How did you hear about us? What position are you applying for?

_________________________

What are your salary expectations? Are you able to travel if a job requires it?

____________________	YES NO

Select which employment you are you interested in:

Regular Full-Time	Temporary Full-Time	Regular Part-Time Temporary Part-Time	Summer Help

Were you previously employed by Martech/Medcomp/Point?

YES NO

IF YES, by which Company and when?

_________________________________________________________________________

Have you ever applied for a position with Martech/Medcomp/Point?

YES NO

IF YES, with which Company and when?

_________________________________________________________________________

If you are offered a job/position, on what date will you be available for work?

_________________________________________________________________________

Summarize Special Skills and Qualifications Acquired from Employment or Other Experience:

_________________________________________________________________________

_________________________________________________________________________

Please list all friends and/or relatives presently working for Martech/Medcomp/Point:

_________________________________________________________________________

_________________________________________________________________________

Are you able to perform the essential functions of the job for which you are applying, with or without an accommodation?

YES NO

If an accommodation is necessary, please state the accommodation needed:

_________________________________________________________________________

_________________________________________________________________________

In the past seven (7) years, have you ever been convicted of, pled no contest/nolo contendere to or pled guilty to a crime? Please include all misdemeanors and felonies. You may exclude minor traffic offenses that do not involve alcohol or drugs and convictions or pleas which have been deemed sealed, annulled or expunged by law.

YES NO

IF YES, please explain in full, indicating charge, date of conviction, county and state where the violation took place, sentence imposed, jail/prison term served and terms and conditions of parole or probation, if any. Use additional paper if necessary. NOTE: Answering “Yes” to this question is not an automatic bar to employment. A careful and thorough investigation will be made. Consideration will be given to the amount of time since the conviction, your employment history, the relationship between the job you are being considered for and the crime involved and any other circumstances or information that would pertain to your employment and the safe and efficient operation of the business. Failure to answer this question truthfully may be grounds for denial or termination of employment.

EXPLAINATION:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

AGREEMENT TO TERMS & CONDITIONS

If I am employed, in consideration thereof, I agree to conform to the rules and regulations of Martech, Medcomp or Point and I recognize, understand and agree that my employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of Martech, Medcomp or Point. I understand that no one other than the President of Martech, Medcomp or Point has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, and that any such agreement must be in writing and signed by the President of Martech, Medcomp or Point.

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I authorize the references 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 all parties from all liability from any damage that may results from furnishing same to you. I also agree to permit Martech, Medcomp or Point to conduct substance abuse tests and any other background investigative procedures it deems appropriate with respect to my application and, in the event of hire, while employed.

In the event of employment, I understand that false, incomplete or misleading information given in my application or interview(s) may result in discharge. I also understand and agree that employment may be subject to my taking a physical examination from the Martech, Medcomp or Point physician board, and that in his/her opinion I must be physically and mentally able to perform the work for which I am applying or being considered, with or without reasonable accommodation. I understand, also, that I am required to abide by all rules and regulations of Martech, Medcomp or Point.

This application for employment will remain active for 90 days from the date of the application.

Signature Date

Signature of Applicant	Date