Boardman Medical Supply Co., Inc. considers applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applied For (required):  Other:
Full Name: (First & Last Name) *Required If you are under 18 years of age, can you provide required proof of eligibility to work? 
YES   NO
How did you hear about us?
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Employment Agency Relative or Other:
On what date would you be available to start?:
   
Phone Number: 2nd Phone:
E-mail Address: (required)
Have you ever worked under another name? Yes No
If yes, enter name(s)?

Current Address:
Street: City:
State: Zip:

Have you ever applied with us before? Yes No If so, when?
Were you ever employed with us before? Yes No If so, when?
Are you currently Employed? Yes No
May we contact your current employer? Yes No
Are you currently on "Lay-Off" status and subject to recall? Yes No
Are you allowed to work in the US? Yes No
Are you available to work Full Time? Yes No
Have you been convicted of a Felony in the last 7 years? Yes No
If yes, please explain:


Please list your most RECENT employment FIRST

Company 1: Position Title:
Address: Supervisor Name:
Employer Phone: May We contact this Employer? Yes No
Primary Duties:
Start Date: End Date:
Starting Salary: Ending Salary:
Reason for Leaving:
Company 2: Position Title:
Address: Supervisor Name:
Employer Phone: May We contact this Employer? Yes No
Primary Duties:
Start Date: End Date:
Starting Salary: Ending Salary:
Reason for Leaving:
Company 3: Position Title:
Address: Supervisor Name:
Employer Phone: May We contact this Employer? Yes No
Primary Duties:
Start Date: End Date:
Starting Salary: Ending Salary:
Reason for Leaving:
Education
Name/Location: Major/Course Type of Degree
High School:
Last Year Completed: 9th 10th 11th 12th
Graduated? Yes No

Name/Location Major/Course Type of Degree
College:
Last Year Completed: 1st 2nd 3rd 4th
Graduated? Yes No

Name/Location Major/Course Type of Degree
Grad School:
Last Year Completed: 1st 2nd 3rd 4th
Graduated? Yes No

Name/Location Major/Course Type of Degree
Other:
Last Year Completed: 1st 2nd 3rd 4th
Graduated? Yes No


List 3 Business or Education References that are not related to you:
Name: Phone: Yrs Known:
Name: Phone: Yrs Known:
Name: Phone: Yrs Known:


Wage / Salary Requirements  
Additional Information - Other Qualifications:
Summarize special job related skills and qualifications acquired from employment or other experience.


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Boardman Medical Supply.

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