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Application Form
Position Desire
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Date Available
Type the date you are available to start working.
MM
DD
YYYY
Type Of Employment Desire
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Part Time
Full Time
Name
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First Name
Last Name
Date Of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
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(###)
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Alternate Phone
(###)
###
####
Email Address
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Valid Driver's License
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Yes
No
Class
CDL
Yes
No
Level of Education
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High School
GED
College 0-3 Years
Associate
Bachelor
Masters
Work Experience
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Please specify Last Work Experience description, as well, how many years of work experience in the last job.
Title and Duties Performed
Please Specify a Brief Description of Duties performed.
Supervisor Name and Phone Number
Please specify your Supervisor Name in your last work experience, and phone number.
Reference One
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Reference Two
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Reference Three
*
Have you ever serve in the Military?
Yes
No
Do you Speak any other Language(s)?Specify
Do you have the legal right to obtain employment in the United States?
Yes
No
Can you perform the essential functions and responsibilities of the position for which you are applying?
Yes
No
If not, explain:
I have applied for employment with INTEGRITY MEDICAL TRANSPORTATlON CORP. in a position that requires me to operate an automobile. As a condition for my application being considered, I understand and agree to undergo substance screening. I understand that if my test results are positive, I shall not be considered further by IMT for driving related position. I Hereby Authorize any physician, laboratory, hospital or medical professional retained by for screening purposes to conduct such screening and to provide the results to IMT Corp. and I release to any person affiliated to IMT Corp. and any such institution or person conducting the screening, from liability therefore.
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Name and Date
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Drug Testing Consent
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Yes, I Consent.
By Accepting employment with Integrity Medical Transportation Corp. I Hereby Acknowledge the right of Integrity Medical Transportation Corp. to make a driving record check with the Register of Motor Vehicle.
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Driver License Number
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Signature
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I hereby authorize ____________________ and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: Verification of social security number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registrations and any other public records. I Authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, digital or copy form. I hereby release INTEGRITY MEDICAL TRANSPORTATION, CORP and its agents, officials, representatives or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to relapse. You may contact me as indicated bellow; I understand that a copy of this authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices.
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Background Check Release Consent.
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Yes, I Consent and have read all the information above.
Social Security
*
Thank you!
Drivers requirements
Be at least 21 years of age.
Have at least 3 year of licensed driving experience in the U.S or PR.
Have a valid U.S. driver's license.
Time-Off Request Form
Time-Off Request
Date
*
MM
DD
YYYY
Employee's Name
*
First Name
Last Name
Time Off Requested
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Reason for Time Off
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Comments
Employee's Digital Signature
*
Agree
*
Thank you!
