Application for Employment

Education

A “yes” answer to any of above will not necessarily exclude you from consideration.

Under the Federal Statutes, an employer has the right to make reasonable pre-employment inquires into your ability to perform job-related functions. Many of the job assignments require strenuous physical labor for sustained periods of time or highly developed communication skills. The information you give below is for the limited purpose for our management to determine your ability to perform the job related functions.

Personal References

Former Employers

I hereby authorize investigation of all information concerning my previous employment and any pertinent information personal and otherwise, and release all parties from liability for any damage that may result from furnishing same to Mid-Cities Home Medical / HomePoint Home Medical Company. I declare that all statements contained in this application are true and correct, and I understand that false or inaccurate information will be the basis for dismissal. I hereby declare that I have legal status to work in the United States.

This application shall remain current for only thirty (30) calendar days. After that time, if you have not heard from Mid-Cities Medical and still wish to be considered for employment, it will be necessary for you to fill out a new application.