Hub’s Home Oxygen & Medical Supplies, Inc.
EMPLOYMENT APPLICATION
Date: ____/____/____
Last Name:______First Name: ______
Address: ______City: ______
State: ______Zip: ______
Home Phone: ______Cell Phone: ______
Email Address: ______Driver’s License #______
Position Applied For: ______Minimum Wage Expected: $______
Are you 17 years of age or older: YES or NOAre you a USA Citizen? YES or NO
Have in the lived in the State of PA for more two years? Y or N
Have you ever been convicted of a crime? YES or NO
If so, when, where, and disposition: ______
Are you currently excluded, suspended, debarred or otherwise ineligible to participate in the federal health care programs or in federal procurement or non-procurement programs; or have you been convicted of a criminal offense related to the provision of healthcare items or services, but have not yet been excluded, debarred, suspended, or otherwise declared ineligible; or have you been convicted of a criminal offense related to the provision of health care items or services and have not been reinstated in the federal health care programs after a period exclusion, suspension, debarment, or ineligibility. YES or NO
Are you, to the best of your knowledge, under investigation or otherwise aware of any circumstances which may result in your being excluded from participation in the federal healthcare programs? YES or NO
I understand that my employment is provisional based upon the outcome of my criminal back ground check and exclusion investigations.
______(initial)
Check this box if a resume is attached. The information below is not required to be filled out if a resume is attached and contains the following information. Signature is still required.
EDUCATION (ListHigh School, College, and TechnicalSchools) :
SchoolMajor CourseYears Complete
______
______
WORK EXPERIENCE:
Employer: ______
Job Title: ______Supervisor: ______
Telephone: ______Wage: ______Dates: ______
Describe your Duties: ______
Reason for Leaving: ______
______
Employer: ______
Job Title: ______Supervisor: ______
Telephone: ______Wage: ______Dates: ______
Describe your Duties: ______
Reason for Leaving: ______
Applicant’s Authorization
I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, relating to my employment with the former employer. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment. I, also, hereby release the above named former employer, and its agents and employees, from all liability, for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information.
I certify that the statements and facts contained in this application are true to the best of my knowledge and understand that false statements or misrepresentations are grounds for dismissal.
Applicant Signature:______Date:______