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PERSONAL INFORMATION

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number *

Email Address *

Are you over 18? *

YesNo

Do you have a valid driver’s license? *

YesNo

Is there any reason you cannot be at work on time and on a consistent basis? *

YesNo

EMPLOYMENT DESIRED

Have you ever applied to this company before? If so, when? *

Date you can start? *

Referred By?

Do you have family or friends currently employed by PAL Health Technologies?

YesNo

If Yes, please give name and relationship:

EDUCATION

High School *

Name and Location of School *

Number of years attended Degree earned (Y/N & type) *

Subjects studied *

College

Name and Location of School

Number of years attended Degree earned (Y/N & type)

Subjects studied

Trade, Business, or Correspondence School

Name and Location of School

Number of years attended Degree earned (Y/N & type)

Subjects studied

PREVIOUS EMPLOYMENT

Employer name and address: *

Position title/duties: *

Supervisor: Phone: May we contact this employer: *

Start date/End date: Reason for Leaving: *

Employer name and address: *

Position title/duties: *

Supervisor: Phone: May we contact this employer: *

Start date/End date: Reason for Leaving: *

Employer name and address: *

Position title/duties: *

Supervisor: Phone: May we contact this employer: *

Start date/End date: Reason for Leaving: *

Have you ever been dismissed or forced to resign from any employment? If yes, identify name(s), reason(s), and relevant dates: *

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PAL Health Technologies is an equal opportunity employer. Applicants will receive consideration for positions, without regard to race, color, religion, age, sex, except where sex is a bonafide occupational qualification, sexual orientation, marital status, individuals with disabilities, and equally to disabled veterans and veterans of the Vietnam era.

APPLICANT AGREEMENT (Please be sure to read before signing!) 1. Read, Initial and Date Each Paragraph 2. Read, Initial and Date at the end.

I affirm that the statements made on this application, including all statements concerning my former employment, are true and complete. I authorize PAL Health Technologies to investigate any statement contained in any part of this application (including but not limited to education, employment), and I understand that any false statement, omission of fact, or misrepresentation of facts on this application or other forms provided to PAL will constitute a legitimate and non-discriminatory reason to not hire me. In addition, if hired, I understand that any false statement, omission of fact, or misrepresentation of facts with this Application or other forms provided to PAL shall constitute a legitimate and non-discriminatory reason for termination. (Please initial & date) *

To allow the Company to fully consider me as an Applicant for potential hire, I also authorize and request each former employer, except as indicated, and any person, firm, or corporation given as a reference, to answer all questions that may be asked and to give all information that may be sought concerning me, my work, habits, character, skills, or actions in any transaction. I release all parties from all liability for any damage that may result from furnishing such information to PAL. (Please initial & date) *

I understand that completing this Application does not constitute an offer of employment by PAL Health Technologies. In addition, I understand and agree that, if offered employment by PAL, this Application for Employment does not constitute an employment agreement between me and PAL Health Technologies. If I am hired, I understand and agree that, unless a written employment agreement for a specified period of time is entered into and signed by myself, and by the Chief Executive Officer for the employer, my employment is not for a definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause. (Please initial & date) *

I realize that any offer of employment is dependent upon successfully passing a drug screen and fitness for work physical and completion of a thorough background investigation. If I do not pass the drug screen, physical and/or background investigation, I understand that and agree that the offer of employment will be withdrawn and that I will have no recourse whatsoever. (Please initial & date) *

By my signature on this application, I acknowledge that the Company did not inquire about and I did not provide any information regarding conviction/arrest records that have been sealed or expunged. By my signature on this Application for Employment, I also represent that I have read the Applicant Agreement in full, that I understand the Applicant Agreement and that I have knowingly and voluntarily agreed to it on the date set forth below. (Please initial & date) *

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PERSONAL INFORMATION

Are you over 18? *

Do you have a valid driver’s license? *

Is there any reason you cannot be at work on time and on a consistent basis? *

EMPLOYMENT DESIRED

Position

Do you have family or friends currently employed by PAL Health Technologies?

EDUCATION

PREVIOUS EMPLOYMENT

APPLICANT AGREEMENT (Please be sure to read before signing!) 1. Read, Initial and Date Each Paragraph 2. Read, Initial and Date at the end.

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