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Careers

Position(s) applying for*:

Will you accept (check one or more)

Full Time
Part Time
Temporary

Date Available:

Personal Information

Last Name*:

First Name*:

Middle Initial:

Maiden Name:
(if applicable)

Email*:

Home Phone No*:

Daytime Phone No*:

Address:

City*:

State*:

ZIP Code*:

What hours are you available to work?

Have you ever been convicted of a crime (other than minor traffic violations) during the past 7 years?* (conviction is not an automatic bar to employment. All circumstances will be considered)

Yes
No

List any skills or experience which you feel qualifies you for the position you are applying for*.

Educational Information - Please Print
School Type

High School

Name & Address of School

No. Qtr Credits

No. Sem Credits

Degree

Major

School Type

Name & Address of School

No. Qtr Credits

No. Sem Credits

Degree

Major

School Type

Name & Address of School

No. Qtr Credits

No. Sem Credits

Degree

Major

School Type

Name & Address of School

No. Qtr Credits

No. Sem Credits

Degree

Major

List other skills (accounting, clerical, teaching, etc)

List any special courses, seminars, workshops, training sessions, etc. that you have attended and/or any certificates that relate to this position.

Please type a short paragraph describing why you are interested in employment with SISU Medical Solutions, LLC

References

Name

Business

Yrs Acquainted

Address, City, State, Zip

Phone No.

Name

Business

Yrs Acquainted

Address, City, State, Zip

Phone No.

Name

Business

Yrs Acquainted

Address, City, State, Zip

Phone No.

THIS AREA MUST BE COMPLETED IN ITS ENTIRETY

Employment - Provide a complete account of your work experience; list your current or most recent position first.

Name of Employer*

Your Title*

Supervisor & Title*

Specific Duties*

From (month/year)*

Total*

Hrs/Wk*

Wage

Reason for seeking other employment/reason for leaving*:

Name of Employer

Your Title

Supervisor & Title

Specific Duties

From (month/year)

To(month/year)

Total

Hrs/Wk

Wage

Reason for seeking other employment/reason for leaving:

Name of Employer

Your Title

Supervisor & Title

Specific Duties

From (month/year)

Total

Hrs/Wk

Wage

Reason for seeking other employment/reason for leaving:

Name of Employer

Your Title

Supervisor & Title

Specific Duties

From (month/year)

Total

Hrs/Wk

Wage

Reason for seeking other employment/reason for leaving:

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Please Read
By submitting this application to SISU Medical Solutions and desiring them to be informed as to my previous record and qualifications, I hereby authorize SISU Medical Solutions to investigate my past record. Permission is granted to discover any and all information, which may concern my suitability for employment. I release my present and past employers, references, and all others from any damage resulting from the furnishing of said information. I understand that, if hired, the employment relationship is contingent upon the mutual benefit of both parties and can be terminated by either party upon furnishing proper notification of the other party. I further understand that the misrepresentation of omission of information requested on this application can result in my disqualification or dismissal.

By submitting this application, I certify that I have read and understood the above statement, and the information provided herein is complete and factual.