Medical Supplies and Equipment by MedTek

Equal Opportunity and Affirmative Action

Please Complete Application in Full

Last Name

First Name

Middle Name

Current Address

City

County

State

Zip Code

Social Security Number

Home Phone

Work Phone

Source of Referral

Recruiting Method:

Have you ever been convicted of a felony or a misdeameanor, or have you ever plead no contest to any criminal charges?

Yes No

Provide date, city, state and an explanation for any yes responses:

Criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.

Are you debarred from working in a federally funded program, i.e. Medicaid. Medicare?	Yes No
Can you perform the functions of the job for which you are applying, either with or without reasonable accomodation?	Yes No
Do you have any relatives employed by Intermountain Health Care?	Yes No
If yes, Where? Relationship:
Have you ever been employed by or are you currently employed by Intermountain Health Care?	Yes No
If yes, Where? When?

Work Availability

Position(s) Desired:

Title

Type of Employment:
Full-Time
Part-Time
Temporary
On-Call

Work Schedule/Shift:
Days
Evenings
Nights

Hours Available:
Weekends Yes No

Rotating
Weekends Yes No

Current Salary:

Minimum Salary Requirement:

Date Available for Work:

Job Skills

Check all that you have experience with:

PC
Windows
PC Graphics

Spreadsheet
LAN
Tandem

List specific software programs used:

IDX, Clinical Workstation, WordPerfect, Lotus, Oracle, etc.

Typing Speed: WPM 10-Key by Touch? Yes No

Education

Have you graduated from High School or completed the GED equivalent? Yes No

List all degrees that you have received. List your highest degree first. Do not list degrees that you are currently working toward.

MAJOR

DEGREE

SCHOOL

GRADUATION DATE

Are you currently enrolled? Yes No Last year attended: Major:

List last level of school completed:

Undergraduate

Graduate

Licensure / Registration Certification

List all professional licenses, registration, and certifications.

LIC/REG/CERT TYPE

LICENSE #

STATE

EXPIRATION DATE

Do you have any pending restrictions and/or suspensions on your current professional license/registration that would restrain you from performing in this position?	Yes No
Have you ever been refused professional licensure, or had a license/registration suspended or revoked?	Yes No

If yes, please explain:

List any trade or professional organization of which you are a member, include offices held:

List any special skills:

Employment History

How many years of experience do you have related to this position?

May we contact your current employer?

Yes No

NOTE: If your current or most recent employer is not contacted before an offer of employment is made, then any offer of employment that is made will be subject to IHC subsequently contacting such employer, and may be withdrawn based on the information received from such employer.

If not, why?

Start with your most recent employment, give a complete record of all employment and reasons for periods of unemployment.

Company Name

Address

City

County

State

Zip Code

Type of Business

Supervisors Name, Title & Phone

Date Employed

Date Left

Title and Duties

Reason for Leaving

If your employment records exist under another name, please specify

Final Salary

Company Name

Address

City

County

State

Zip Code

Type of Business

Supervisors Name, Title & Phone

Date Employed

Date Left

Title and Duties

Reason for Leaving

If your employment records exist under another name, please specify

Final Salary

Company Name

Address

City

County

State

Zip Code

Type of Business

Supervisors Name, Title & Phone

Date Employed

Date Left

Title and Duties

Reason for Leaving

If your employment records exist under another name, please specify

Final Salary

References

Give three additional work-related references.

NAME OF
REFERENCE

OCCUPATION
OR TITLE

FIRM NAME
AND ADDRESS

PHONE AND
AREA CODE

YEARS
KNOWN

Certification and Agreement

I certifty that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal.

I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, typing tests, etc.) of information contained in this application.

I authorize any and all persons, companies or agencies to release to Medtek any and all information they may have which is revelant to the application process. I also release all such parties from any liability that may result from furnishing information to Medtek.

I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by the appropriate Human Resources Department.

I understand that if I am employed with Medtek, my employment will be at-will. As such, it can be terminated by Medtek with or without notice, at any time, and for any reason not prohibited by law. I agree that if I am employed by Medtek I will review the information contained in the General Information Handbook.

I understand that any employment offer is contingent upon the following: (1) producing documents establishing my eligibility to work in the United States; (2) satisfactorily passing the pre-employment drug screen, criminal background and reference checks; and (3) complying with Medtek pre-employment application procedures.

By choosing "I agree to the above" I acknowledge that I have read the certification and agreement and agree to abide by its terms.

I agree to the above. I do not agree to the above.