MEDITECH
Application for Employment

Please complete the following (circle where applicable)
 
Date: ___________________
   
Name: _________________________________________________
 
Present Address
 
Number, Street, Apt #: _____________________________________
City, State, Zip Code: _____________________________________
Home Telephone #: (_____)________________
Daytime Telephone #: (_____)________________
 
Permanent Address
 
Number, Street, Apt #: _____________________________________
City, State, Zip Code: _____________________________________
Home Telephone #: (_____)________________
   
E-Mail Address: _____________________________________
   
Are you authorized to work in the U.S.? No / Yes
 
If so, list authorization: _____________________
 
Type of work desired? (Circle Two)   Permanent/Temporary         Full-Time/Part-Time  
 
Position for which you are applying: ________________________________________________
 
Locations:      Westwood / Norwood / Canton / Framingham / Fall River / No Preference   
 
What shifts are you willing to work?       1st / 2nd / 3rd    
   
Are you willing to work weekends and/or holidays?  No / Yes  
 
Are you willing to travel?      No / Yes  
 
Are you willing to relocate?      No / Yes  
   
Have you ever applied to this company before?      No / Yes  
 
Salary Desired?     $__________________
 
 
 
 
How did you hear about this position at MEDITECH?    Web Site
 College (If yes, name): _____________________
 Staff Member (If yes, name/relationship):
____________________________________
 Other (Please specify): ___________________
     
Please list names of relatives in our employ:   _____________________________________
     
Are you currently in a military reserve unit, or do you have any other current military obligations?    No / Yes  (If yes, please explain):
_____________________________________
_____________________________________
_____________________________________
     
Have you ever been convicted of a felony?    No / Yes
     
Have you ever been convicted of a misdemeanor within the past five years, with the exception of a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace? (A conviction will not necessarily disqualify you from the position you are applying.)    No / Yes  (If yes, please explain):


(SEALED RECORD NOTICE: An applicant for employment with a sealed record on file with the Commissioner of Probation may answer "no record" with respect to an inquiry herein relative to prior arrests, criminal court appearances, or convictions. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.)

Educational Record
High School Name:    _____________________________________
Location: _____________________________________
   
Did you graduate? No / Yes
 
College Name:    _____________________________________
Location: _____________________________________
Major:     ___________________        Minor:     ___________________
 
Did you graduate? No / Yes
Official cumulative grade point average upon graduation:      ___________________
 
Other School Name:    _____________________________________
Location: _____________________________________
Major:     ___________________        Minor:     ___________________
Did you graduate? No / Yes
 
Other Training (Please specify):    _____________________________________
 
 
 
 
 

Employment Record
(Please list MOST recent position first)
 
A. Company: _____________________________________
Address: _____________________________________
Telephone #: _____________________________________
Your Job Title: _____________________________________
Initial Salary: $_____________________________________
Final Salary: $_____________________________________
Full-Time / Part-Time      If part-time, number of hours worked?     ___________________

Employed From (Month/Day/Year):   

_________________        To (Month/Date/Year):    ________________
Supervisor: _____________________________________
Reason Left: _____________________________________
May we contact this employer? No / Yes
 
 
 
 
 
B. Company: _____________________________________
Address: _____________________________________
Telephone #: _____________________________________
Your Job Title: _____________________________________
Initial Salary: $_____________________________________
Final Salary: $_____________________________________
Full-Time / Part-Time      If part-time, number of hours worked?     ___________________

Employed From (Month/Day/Year):   

_________________        To (Month/Date/Year):    ________________
Supervisor: _____________________________________
Reason Left: _____________________________________
May we contact this employer? No / Yes
 
 
 
 
 
C. Company: _____________________________________
Address: _____________________________________
Telephone #: _____________________________________
Your Job Title: _____________________________________
Initial Salary: $_____________________________________
Final Salary: $_____________________________________
Full-Time / Part-Time      If part-time, number of hours worked?     ___________________

Employed From (Month/Day/Year):   

_________________        To (Month/Date/Year):    _______________
Supervisor: _____________________________________
Reason Left: _____________________________________
May we contact this employer? No / Yes
 
 
 
 
D. Company: _____________________________________
Address: _____________________________________
Telephone #: _____________________________________
Your Job Title: _____________________________________
Initial Salary: $_____________________________________
Final Salary: $_____________________________________
Full-Time / Part-Time      If part-time, number of hours worked?     ___________________

Employed From (Month/Day/Year):   

_________________        To (Month/Date/Year):    ________________
Supervisor: _____________________________________
Reason Left: _____________________________________
May we contact this employer? No / Yes
 
 
E. Company: _____________________________________
Address: _____________________________________
Telephone #: _____________________________________
Your Job Title: _____________________________________
Initial Salary: $_____________________________________
Final Salary: $_____________________________________
Full-Time / Part-Time      If part-time, number of hours worked?     ___________________

Employed From (Month/Day/Year):   

_________________        To (Month/Date/Year):    _________________
Supervisor: _____________________________________
Reason Left: _____________________________________
May we contact this employer? No / Yes
 
 
When could you begin employment at MEDITECH:       _________________
   
 
Please list any special skills, foreign languages, etc.:
 
Please use the space below for any additional information which you consider of value to us in considering you for employment:


I certify that all statements made by me on this application are correct to the best of my knowledge.  I authorize Medical Information Technology, Inc. (MEDITECH) to make any inquiries to determine my suitability for employment, except where written statement specifically requests that no reference be made.  I understand that any false or misrepresented information on this application may be the cause for future dismissal.

I also understand this Employment Application is not a Contract of Employment.  Any individual who is hired may voluntarily leave employment upon proper notice or may be terminated by MEDITECH at any time and for any reason. I further agree that upon employment, I will be required to sign MEDITECH’s Employment Agreement on Proprietary and Confidential Information.
 

Applicant's Signature:      _____________________________________
 
Date:      _____________________________________