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Apparel
Body Positioning and Pressure Relief
Diagnostics
Drainage and Suction
Durable Medical Equipment
Gloves
HouseKeeping
Incontinence
IV Therapy
Lab Supplies
Linens
Needles and Syringes
Nursing Supplies
Nutrition
Orthopedic
Ostomy
Over the Counter
Personal Care
PPE COVID-19
Respiratory
Skin Care
Wound Care
   


Employment Application
All blanks must be filled and all questions answered – regardless of whether a resume is attached.

NAME:
ADDRESS:
CITY:
STATE OR PROVINCE/ZIP:
DESIRED WAGE:

 

Yes No Are you 18 years old or older? 
Yes   No   Do you have a high school diploma or  equivalent?
Yes   No    Are you willing to undergo a drug screen?
Yes   No    Can you work in a non-smoking environment?
Yes   No    Can you provide proof of legal right to work in this country?
Yes   No    Can you read and write English?
Yes   No    Do you have special licensing or
certifications?  If yes, field:                          
Yes   No    Have you read the job description for the position for which you are applying?
Yes   No    Are you able to perform all of the duties listed?
Yes   No    ARMED FORCES work experience: 
If yes, from:  to:

DATE:
PHONE:
POSITION APPLYING FOR:
EMAIL:

Availability:

Have you ever been disciplined or fired from a job?  If yes,
     Have you been convicted of a felony within the last 7 years?  (A yes or no answer to this question does not necessarily disqualify applicant from employment.)
    Have you worked for Grove Medical before?
When?
     Do you know an employee of this           company?  Who? 

How did you hear about us?

Begin with your present or last work experience.    

Company:
Address:
Last position title:
Reason for leaving:
Immediate supervisor:

Employed from:to:

City:

State:  Zip:

Salary: starting: ending:

Hours worked/week:

Phone:

Duties and responsibilities:
My initials, , indicate my willingness for you to talk with this employer.

Company:                                                                      
Address:                                                                         
Last position title:                                                            
Reason for leaving:                                                           
Immediate supervisor:                                                       

Employed from:                             to:                                  
City:                                             State:           Zip:                         
Salary: starting:                            ending:                           
Hours worked/week:                                                           
Phone:                                                                                          

Duties and responsibilities:                                                                                                                                             
                                                                                                                                                                                    
My initials,           , indicate my willingness for you to talk with this employer.

Company:                                                                      
Address:                                                                         
Last position title:                                                            
Reason for leaving:                                                           
Immediate supervisor:                                                       

Employed from:                             to:                                  
City:                                             State:          Zip:                         
Salary: starting:                            ending:                           
Hours worked/week:                                                           
Phone:                                                                                          

Duties and responsibilities:                                                                                                                                             
                                                                                                                                                                                    
My initials,           , indicate my willingness for you to talk with this employer.

DO YOU HAVE EXPERIENCE IN THE FOLLOWING:

“ Data Entry
“ Inventory Control
“ Accounts Receivable/Payable
“ RF Devices/Scanners
“ Pick Sheets
“ Packing

“ Shipping
“ Supervision
“ Switchboard
“ MS Excel
“ MS Word
“ MS Outlook

“ Forklift
“ Calculator
“ Typing Speed                   
“ Internet Use
“ Computer Software

“ UPS/FedEx Software
“ Palletizing
“ Other                                  

 

APPLICANT'S AGREEMENT

 High School:  ______________________________              College:____________________________________________
                                                                                       Dates Attended:______________________________________
Degree Obtained:___________________________               Degree Obtained:_____________________________________

 

 

I UNDERSTAND AND AGREE THAT:
1.  If I misrepresent or deliberately leave out a fact in my application, I may be refused employment or, if employed, I may be terminated.
2.  If employed, I may terminate my employment at any time without notice or cause, and the Company may terminate or modify the relationship at any time without notice or cause.  I agree to conform to the rules and regulations of the Company and I understand that no department head or representative of the Company, other than the president or a designated officer of the Company, has the authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the Agreement.
3.  As a condition of employment or my continued employment, I may be requested by the Company to submit to a drug and alcohol screen, and/or other tests and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in my immediate termination.
4.  I authorize the Company to verify all information provided by me and to contact any organization or individual that I have listed on my employment application or resume or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my experience, skills, and abilities.  I understand that I am consenting to the release of any reference-related information about me held or known by my former employers, supervisors, and co-workers.  In addition, I consent to the release of any information about my education, experience, abilities, performance, attendance, conduct, or other work-related characteristics or issues held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, and friends and acquaintances that the Company might contact in the course of conducting a reference check or background investigation of my suitability for employment or procuring or having a police report prepared for this purpose.
I understand and acknowledge that this release of information can involve my qualifications, performance, credentials, criminal record or other characteristics or factors affecting my suitability for employment with the Company.
5.  In exchange for the Company’s consideration of my employment application, I release the Company and any organization or individual it may contact from any and all damages, liabilities, or claims that may exist or arise relating in any way to the release or receipt of information as provided herein.  I further agree not to file or pursue any complaint claims or legal actions of any kind against any organization or individual that provides work-related information about me to the Company or its agents in accordance with the terms and intent of this release.  I also agree not to file or pursue any complaints, claims, or legal actions against the Company or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me.
6.  If employed, I understand that my employment is for no definite period of time, and if terminated, the Company is liable only for wages or salary earned as of the date of termination.
7.  I have read, understand and agree to the above. I hereby certify that the facts I have provided in this employment application are true and complete.

Signature:                                                                                                                     Date: