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Customer Service Representative Application

* - Indicates required fields

Personal Information

How did you hear about us:

Education

High School

Did you graduate?
Degree Earned?

Undergraduate College

Did you graduate?

Graduate Professional

Did you graduate?

Other

Did you graduate?

Employment History

May we contact for reference?

Date Employed

Salary

Status

May we contact for reference?

Date Employed

Salary

Status

May we contact for reference?

Date Employed

Salary

Status

May we contact for reference?

Date Employed

Salary

Status

May we contact for reference?

Date Employed

Salary

Status

Specialized Training & Activities

General Information

Are you legally authorized to work in the United States?*
Are you legally authorized to work in the United States?* (If hired, verification will be required upon employment)
Are you 18 years of age or older?*
Are you 18 years of age or older?*
Have you ever applied with Alick's Home Medical, Inc before?
Have you ever applied with Alick's Home Medical, Inc before?*
Have you ever worked for Alick's Home Medical, Inc before?
Have you ever worked for Alick's Home Medical, Inc before?*
Do you have any relatives currently working for for Alick's Home Medical, Inc?*
Do you have any relatives currently working for for Alick's Home Medical, Inc?*
Have you ever been convicted of a felony which has not been expunged or sealed by a court?*
Have you ever been convicted of a felony which has not been expunged or sealed by a court?*
Have you ever been fired or asked to resign from a job?*
Have you ever been fired or asked to resign from a job?*

REFERENCES

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APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION:-
IMPORTANT: Read before signing.

I have read and fully understand the questions asked in this application. I certify that all answers given by me are true, accurate, and complete. I hereby authorize Alick's Home Medical, Inc to obtain employment and educational references for me from all current and prior employers and educational institutions and release all persons from liability for providing such reference information. I hereby release Alick's Home Medical Inc from any/all liability of whatever kind and nature, which at any time, could result from obtaining and basing an employment decision on such information. I understand that, if employed, Alick's Home Medical Inc may terminate my employment if I have made any false statements or misrepresentations in this application or during the interview process.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Alick's Home Medical Inc. However, I further understand that neither the policies, rules, or regulations of employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either Alick's Home Medical Inc or I may terminate my employment at any time with or without notice or cause. I understand that Alick's Home Medical and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance, or otherwise change all policies, procedures, benefits, or other terms or conditions of employment

My signature below indicates that I have read, understand, and agree to the above statements.

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