Drug Screen Tech

First name*

Last name*

Email address*

Location

Phone number*

Resume*

References*

Referral Name

Highest Education Attained*

College/University*

Desired Salary

Earliest Start Date*

Work Weekends*

Work Evenings*

Languages Spoken*

Felony or Misdemeanor Conviction*

Felony or Misdemeanor Explanation*

If hired, can you provide proof that you are eligible to work in the United States?*

Why are you seeking new employment opportunities?*

What type of employment are you looking for?*

Years of Customer Service Experience:*

Years of Healthcare Experience:*

Have you ever been involved in any federal or state investigations concerning fraud or abuse? If yes, please email a statement to [email protected].*

Have you ever or are you currently excluded from providing services to patients that are covered under any federally funded health-care plan, including Medicare, Medicaid, & all other federal health-care programs? If yes, please email a statement to [email protected].*

Location available to work: (Choose all that apply)*

What is your availability? (Choose all that apply)*

Please explain any gaps in your employment history:*

Have you ever previously worked for MMSI, NowCare, or Bayview?*

Have you ever been employed by MMSI, NowCare, or Bayview under a different name? If so, please provide that name.*

Do you have a relative working for MMSI, NowCare, or Bayview? If yes, please provide their name.*

Current Employer Name*

Job Title*

Job Duties*

Dates of Employment*

Reason for Leaving*

Supervisor's Name*

Telephone Number*

Company Name*

Job Title*

Job Duties*

Dates Employed*

Reason for Leaving*

Supervisor's Name*

Company Name*

Job Title*

Job Duties*

Dates Employed*

Reason for Leaving*

Supervisor's Name*

Company Name*

Job Title*

Job Duties*

Dates Employed*

Reason for Leaving*

If you are applying for a clinical position, please list any license, certification, or registration numbers along with the expiration date and type. If you are not applying for a clinical position or this question does not apply to you, please type N/A in the box below.*

Please list any additional certifications (BLS, ACLS, CPR, etc.) and include the expiration date. If this question does not apply to you, please type N/A in the box below.*

Do you have any experience from military service that would be relevant to the job(s) for which you are applying? If yes, explain in detail.

May we contact your present employer for work reference?*

It is the goal of Medical Management Services, Inc. (MMSI) to employ the qualified individual who best matches the requirements for the position to be filled. I certify that the statements herein are made truthfully without evasion and agree that the statements may be investigated and if found false, may subject me to disqualification for employment or be sufficient reason for my dismissal. MMSI reserves the right to make any investigation into my previous employment history, financial, credit or public records, including criminal background through investigative or credit agencies or bureaus of MMSI's choice. I authorize all schools which I attended and all previous employers to furnish to MMSI my record, reason for leaving and all information they may have concerning me and herby release them and MMSI from all liability for any damage whatsoever arising there from.

Please type your name and date in the box below to certify the information above.*

Human Check*