Application Form – Midway Specialty Care Center

Which position are you applying for?

Email *

Name *

First

Last

Address *

City *

State *

ZIP Code *

Are you 18 years old or older? *

Yes
No

Are you either a U.S. citizen or an alien authorized to work in the U.S.? *

Yes
No

Have you ever worked or attended school under another name? If so, under what name?

Desired Position

Location Applying For

Have you previously worked for this company?

Reason for leaving

Former supervisor(s) at this company

How did you learn about this opening?

High School Attended

Graduated?

Yes
No

College/ University Attended

Graduated?

Yes
No

College/ University Course of Study

Postgraduate School Attended

Graduated?

Yes
No

Postgraduate School Course of Study

Other Education, Training, or Certifications Held

Branch of Service

Date Served

Rank at Discharge

Military Education and Training

Prior Employer

Prior Employer Address

Prior Employer City

Prior Employer State

Prior Employer ZIP Code

How long where you with this employer?

Position Held

Reason for Leaving

Manager's Name, Title, and Contact Phone Number

Description of Duty

Starting Salary/ Hourly Rate

Final Salary/ Hourly Rate

Second Prior Employer

Second Prior Employer Address

Second Prior Employer City

Second Prior Employer State

Second Prior Employer ZIP Code

How long where you with this second employer?

Second Position Held

Reason for Leaving Second Employer

Second Manager's Name, Title, and Contact Phone Number

Second Description of Duty

Second Starting Salary/ Hourly Rate

Second Final Salary/ Hourly Rate

Third Prior Employer

Third Prior Employer Address

Third Prior Employer City

Third Prior Employer State

Third Prior Employer ZIP Code

How long where you with this third employer?

Third Position Held

Reason for Leaving Third Employer

Third Description of Duty

Third Manager's Name, Title, and Contact Phone Number

Third Starting Salary/ Hourly Rate

Third Final Salary/ Hourly Rate

Did you work under any other name during the above employment? If yes, please give the name used?

Have you ever been arrested? If yes, please provide details and current status

Applicant Signature *

First

Last

Date of Application *

Do you accept the conditions of the Applicant Waiver? *

Yes
No

APPLICANT WAIVER – I hereby certify that the information hereunder is correct to the best of my knowledge and understand that falsification of this information is grounds for a refusal to hire or, if hired, dismissal. I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you. I authorize you to request and receive such information. In consideration for my employment and my being considered for employment by your company, I agree to adhere to the rules and regulations of the company and hereby acknowledge that these rules and regulations may be changed by your company at any time, at the company’s sole option and without any prior notice. In addition, I acknowledge that my employment may be terminated, and any offer of employment, if such is made, maybe withdrawn, with or without prior notice, at any time, at the option of either the company or myself. I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to assure or make some other personnel move, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or to make any agreement, that is contrary to the foregoing. I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was signed.

Do you accept the conditions of the Employment Application Disclaimer and Acknowledgement? *

Yes
No

EMPLOYMENT APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT – I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization, or company listed on this application to furnish you with any and all information concerning my previous employment, education, and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added, or interpreted at any time, at the company’s sole option, and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.

Is the information you have provided accurate? *

Yes
No