APPLICATION FOR EMPLOYMENT

Please fill out this application completely to help us learn more about you. If you have any questions or need help, please let us
know. Monarch Medical is an equal opportunity employer committed to a policy of non-discrimination in employment and to
having a diverse workforce. Qualified applicants are given consideration for employment without regard to race, sex, marital or
veteran status, religion, color, national origin, age, sexual orientation, the presence of mental, physical or sensory disabilities, or
any other basis prohibited by local, state or federal law. False statements on this application form shall be considered sufficient
cause for termination.

Today’s Date: _________________ Position Applying for:_______________________ Location:_______________

_____________________________________________________________________________________________
Personal Last Name First Name Middle Name
Information _____________________________________________________________________________________________
Address City State Zip Code
_____________________________________________________________________________________________
Home Phone Number Cell Phone Number Email Address

Can you perform the essential functions of the position for which you are applying? ____Yes____No
If you have a disability that requires accommodation to perform the position for which you are applying, please
explain what accommodations would allow you to perform the job successfully:
_____________________________________________________________________________________________

Have you been convicted of a felony or any criminal offense involving dishonesty or violence against a person,
possession or use of weapons or drugs/alcohol, or destruction of property within the past 7 years?
___ Yes ____ No If Yes, please explain the nature of the offense, date, court and description:
_____________________________________________________________________________________________
_

Are you eligible for employment in the United States (proof required upon hire)? ____Yes ____No

Are you less than 18 years of age?* ____ Yes ____ No

*We are required to comply with federal and state law.

Have you previously applied for employment or been employed with Monarch Medical? ____ Yes ____ No
If Yes:
____________________________________________________________________________________________
Location Position Held Dates of Employment

How did you hear about us:______________________________

If referred by a Monarch Medical employee/patient, please list name:____________________________________

When are you available for employment with Monarch Medical? ___________________
Availability Desired Pay:________________

Are you open to relocation: ____ Yes ____ No If Yes, where?_____________________________________

Please list the hours and days of the week you are available to be scheduled:
Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Available

To:

From:
 APPLICATION FOR EMPLOYMENT

Education Level Name & Location Major/Subject Years Completed Graduated?

High School 1 2 3 4 Yes No
College 1 2 3 4 Yes No
University
Business 1 2 3 4 Yes No
Technical School
Other 1 2 3 4 Yes No

Tell us about your last three employers, starting with the most recent one first. You may also list any non-
Work paid or volunteers experience that you believe may be related to the job for which you are applying. Please
Experience provide this information even if you attach a resume.

______________________________________________________________________________________
Company Supervisor’s Name and Title Phone Number
______________________________________________________________________________________
Address Starting Date Ending Date
______________________________________________________________________________________
Position Salary (final or current) Reason for Leaving

______________________________________________________________________________________
Company Supervisor’s Name and Title Phone Number
______________________________________________________________________________________
Address Starting Date Ending Date
______________________________________________________________________________________
Position Salary (final or current) Reason for Leaving

______________________________________________________________________________________
Company Supervisor’s Name and Title Phone Number
______________________________________________________________________________________
Address Starting Date Ending Date
______________________________________________________________________________________
Position Salary (final or current) Reason for Leaving

______________________________________________________________________________________
Company Supervisor’s Name and Title Phone Number
______________________________________________________________________________________
Address Starting Date Ending Date
______________________________________________________________________________________
Position Salary (final or current) Reason for Leaving

Have you even been terminated by an employer ____ Yes ____ No

If Yes, please explain the circumstances:___________________________________________________
 APPLICATION FOR EMPLOYMENT
If we elect to pursue your candidacy beyond the second interview, we will need to check your employment
Reference references. We are interested in speaking with those whom you have reported directly.
List Current and/or previous work supervisor:
______________________________________________________________________________________
Name Phone Number Position Company Length of relationship

Current and/or previous work supervisor:

______________________________________________________________________________________
Name Phone Number Position Company Length of relationship

Anyone else you would encourage us to speak with about why you would be a great addition to our team?
______________________________________________________________________________________
Name Phone Number Position Company Length of relationship
Authorization
Consent for As part of our employment screening and selection procedures, Monarch Medical requires that a pre-employment verification
Release of of background information be conducted on all finalist candidates. This specifically includes, but is not limited to verification
Information of education, employment history, credit history as permitted by the Fair Credit Reporting Act, a review of any local, county,
state, and federal government agency public records, and business and/or personal references.

This Authorization and Release gives your permission to Monarch Medical, or it’s designated agent, to conduct the background
investigation. Further, I authorize the procurement of any other information that relates to my background, character, and
personal reputation that may be deemed relevant to my employment. All information will be proprietary and kept confidential.

I, the undersigned, do hereby certify that the information provided be me in my application for employment, resume or in
verbal discussions relating to my considerations for employment are true and complete to the best of my knowledge. I hereby
authorize Monarch Medical, or it’s designated agent, to 1) investigate the truthfulness of all statements made on my application
or resume, or in verbal statements made by me in the interview process; 2) contact any verification of my education,
employment, personal, credit and motor vehicles records and to receive any criminal history relating to me which may be on
file with any local, state, or federal criminal justice agencies; and 3) disclose verbally or in writing the results of any
investigation with authorized employees or agents of Monarch Medical, involved in the hiring process.

I have read and understand this Authorization and Consent. I request that this document in its original or copy form serve as
my valid authorization to any and all persons, educational institutions, past and/or current employers, organization, credit
agencies, law enforcement or criminal reporting agencies, and other agencies to release all such personal, institutions, agencies,
and organizations providing such information from liability in any or all claims and damages connected with their providing
requested information.

I further agree to indemnify, discharge and forever hold harmless Monarch Medical from any and all damages, claims, losses,
liabilities, costs and expenses incurred as direct or indirect results of any lawsuit or administrative proceeding brought against
Monarch Medical, which is related directly or indirectly to the disclosure of any such information to such investigation.

In consideration of my employment, I agree that my employment and compensation can be terminated with or without cause,
and with or without notice at any time, at the option of either Monarch Medical or myself.
Signature Signature_______________________________________ Date_________________________________
& Date