Job Application – Parker Medical

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Employment Application

Employer:

Parker Medical, Inc.

43 Old Ridgebury Rd.

Danbury, CT 06810 USA

860.350.4304

Driver's License (State/Number)

Who/what referred you to our company

Please list any friends or relatives who work/have worked at Parker Medical, Inc.

Job Position Applied For:

Full Time/ Part Time

Full Time Part Time

Are you age 18 or older:

Yes No

Are you authorized to work in the United States?

Yes No

If offered employment, when are you available to start

List any skills that may be useful for the job you are applying for, including years of experience, and proficiency (include languages spoken/read/written)

1. Previous Employer Name

Dates of Employment (Month/Year)

2. Previous Employer Name

Dates of Employment (Month/Year)

3. Former Employer Name

Dates of Employment (Month/Year)

Applicant's Education and Training: List high school, college, graduate, technical, vocational, etc. Please note any degrees, certifications, special achievements, honors, professional licenses.

Military Servies

Yes No

Specialized Training

Other information: Please provide any other information that may be relevant, including whether you are bound by any agreement with current or past employer(s).

I Certify the information provided in this application is truthful and accurate. I understand that providing false or misleading information is cause for rejection of my application, or if employed, immediate termination.

I authorize PARKER MEDICAL, INC. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to communicate information fully and freely regarding my previous employment and education. I authorize those persons designated as references to communicate personal/professional information about me fully and freely.

I HAVE READ THE ABOVE CERTIFICATION AND UNDERSTAND AND AGREE TO ITS TERMS.

Contact

43 Old Ridgebury Rd.
Danbury, CT 06810 USA

Tel: 860.350.4304
Fax: 860.350.3432

info@parkermed.com