Apply for Employment

Complete the application below. All information is kept confidential and used only to evaluate your suitability for employment.

Last Name

First Name

Middle Name

Street Address

City

State

Zip Code

Home Phone

Cell / Message Phone

E-mail

Position Applied For

Date of Application

On what date are you available to work?

Minimum salary acceptable

Are you available to work

Full Time (40 hours per week) Part Time (Less than 30 hours per week)

Are you 18 years of age or older?

Yes No

May we contact you at work?

Yes No

If necessary, best time to call you at home

Were you referred to us?

Yes No

If yes, name of person or source

Are any of your relatives presently employed with Medical Data Systems, Inc.?

Yes No

If yes, name of relative(s)

Have you ever worked for Medical Data Systems, Inc. before?

Yes No

If yes, where and approximate date

Have you ever applied to Medical Data Systems, Inc. before?

Yes No

If yes, where and approximate date

Do you have the legal right to work in the United States?

Yes No

If hired, you will be required to provide identification to prove eligibility for employment.

Are you able to meet the attendance requirements of the position?

Yes No

Will you work overtime if required?

Yes No

If no, please explain

Have you ever been convicted of, pled nolo contendere (no contest) to, had adjudication withheld, been placed on probation or entered a pretrial diversion program for the commission of a crime other than a minor traffic offense?

Yes No

Answering “yes” to this question will not automatically disqualify you from employment. You should answer “no record” if a conviction has been sealed or expunged or otherwise statutorily eradicated.

If you responded yes, please describe the nature of the crime and your subsequent rehabilitation

High School

School – City, State

Course of Study

Years Completed

Graduated?

Yes No

Degree Obtained

College

School – City, State

Course of Study

Years Completed

Graduated?

Yes No

Degree Obtained

Graduate School

School – City, State

Course of Study

Years Completed

Graduated?

Yes No

Degree Obtained

Technical / Other

School – City, State

Course of Study

Years Completed

Graduated?

Yes No

Degree Obtained

Please list, beginning with your current or most recent employment, any and all prior work experience during the past 10 years. Include military service as part of your employment record.

Most Recent Employer

Company Name

Address

Supervisor

Telephone Number

Job Title

Employed From (Mo & Yr)

Employed To (Mo & Yr)

May MDS contact this employer?

Yes No

Reason for Leaving

Job Duties

Previous Employer

Company Name

Address

Supervisor

Telephone Number

Job Title

Employed From (Mo & Yr)

Employed To (Mo & Yr)

May MDS contact this employer?

Yes No

Reason for Leaving

Job Duties

Previous Employer

Company Name

Address

Supervisor

Telephone Number

Job Title

Employed From (Mo & Yr)

Employed To (Mo & Yr)

May MDS contact this employer?

Yes No

Reason for Leaving

Job Duties

List three business/work references who are not related to you, at least one of whom is a previous supervisor. If not applicable, list three school or personal references who are not related to you.

Reference 1 – Name

Address

Telephone

Years Known

Reference 2 – Name

Address

Telephone

Years Known

Reference 3 – Name

Address

Telephone

Years Known

Summarize any special training, software applications, skills, licenses and/or certificates that may qualify you for this position

Resume / CV and Cover Letter

PDF or Word documents only (.pdf, .doc, .docx). Up to 3 files, 8 MB each.

Application Acknowledgement

Employment is conditioned on the successful completion of the screening process. By submitting this application, I represent that the information provided is given voluntarily and indicates that I have read and understand the importance of supplying complete and accurate information. I am also aware of the possibility of an offer of employment being withdrawn, or my employment being terminated, if any of the information is not complete and correct.

I certify that I have answered the above questions truthfully and have not withheld any information relevant to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements or omissions of the application information, attachments, and supporting documents generally will result in denial of employment or immediate termination, if discovered after hire.

I authorize Medical Data Systems, Inc. to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, and further authorize the references I have listed to disclose to the company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Medical Data Systems, Inc., my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

If hired, I agree to adhere to the rules and policies of Medical Data Systems, Inc. I understand that my employment and compensation can be terminated at any time, with or without cause, and with or without notice, at the option of Medical Data Systems, Inc. or myself. I understand that the President of the company is the only person who will ever have the authority to create any other terms of employment and/or to enter into any employment contract, and that all such contracts must be in writing and signed by both parties. However, I also understand that unless otherwise stated in an employment contract, the company may change, withdraw and interpret other policies (including wages, hours and working conditions) as it deems appropriate.

Electronic Signature – type your full legal name

Date

Medical Data Systems, Inc. d/b/a Medical Revenue Service is an equal opportunity employer. The information you provide is used only to evaluate your suitability for employment and is handled in accordance with our Privacy Notice. If you have difficulty completing this form or need an accommodation, contact MDS-HR@meddatsys.com or 888-773-2255.