Employment Application - ProMed Logistics

Applicant Information

Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email*

Date Available*

Desired Salary

Position Applied For*

Are you a citizen of the United States?*

Yes
No

If no, are you authorized to work in the U.S.?

Yes
No

Have you ever worked for this company?*

Yes
No

If yes, when?

Have you ever been convicted of a felony?*

Yes
No

If yes, explain:

Education

High School

High School	Address	Years: From	To	Did you graduate?

College

College	Address	Years: From	To	Did you graduate?	Degree

Other

Other	Address	Years: From	To	Did you graduate?	Degree

Reference

Please list three professional references.

Reference 1

Full Name	Relationship	Company	Address	Phone

Reference 2

Full Name	Relationship	Company	Address	Phone

Reference 3

Full Name	Relationship	Company	Address	Phone

Previous Employment

Company #1

Phone

Address

Your Supervisor

Your Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes
No

Company #2

Phone

Address

Your Supervisor

Your Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes
No

Company #3

Phone

Address

Your Supervisor

Your Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes
No

Additional Information

List all days / hours you would be willing to work.*

WE OPERATE 24x7 / 365 SO BE AS BROAD AS YOU CAN.

Do you have any physical or mental conditions that would prohibit you from performing medical delivery even in times of bad weather, stressful driving situations or at night?*

Yes
No

If yes, please describe.

Do you take prescription drugs that cause drowsiness, headaches, dizziness, blurred vision, mood altering or cause anxiety?*

Yes
No

If yes, please list.

Do you suffer from seizures?*

Yes
No

Can you lift over 50lbs?*

Yes
No

Do you use illegal drugs?*

Yes
No

Do you use tobacco?*

Yes
No

Do you have difficulty driving at night?*

Yes
No

Do you have difficulty driving in bad weather?*

Yes
No

Do you have difficulty driving on highways/interstates?*

Yes
No

Can you drive in large cities or cities you are not familiar with?*

Yes
No

What kind of work environment do you prefer?*

Check best answer(s)

Low pace
High pace
With team
Alone
Structured work flow
Varied work flow

Has your driver’s license ever been revoked?*

Yes
No

Have you been convicted of any drug or alcohol related incidents?*

Yes
No

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Please be aware our company hires employee and non-employee (contract) workers. Receipt of this application and your being offered a position does not necessarily mean you will be an employee. If you are offered a contract, a separate contract will need to be filled out. This application is only used to gather information about you so we can get a fair assessment of your qualifications and ability to work with MedExpress.

Signature*

Date*