Employment Application

SurgiSource Employment Application

  • Employment Desired

  • Educational History

  • General Information

  • A felony conviction does not necessarily disqualify you from employment.
  • Employers

  • (List employers for past 7 years with most recent first. Upload a file with additional employer information if needed to list last seven years of employment history.)
  • Special Area of Study/Research or Special Training/Skills

  • Military Service

  • References

  • List three business related references.
  • Authorization

  • I certify that the information contained in this application is complete and correct to the best of my knowledge and I understand that falsification or incompleteness of this information may result in my not being considered for employment or dismissal if I am employed. I authorize the references listed on this application to give you any and all information concerning my previous employment and/or education and release all parties from all liability for any damages that may result from furnishing any lawful job related information. I understand that before any offer of employment is extended and/or commences, I may be required to submit to a background check, reference check, and pre-employment drug screen. I also authorize SurgiSource LLC to check my Motor Vehicle Report required as a condition of employment for the position in which I am applying. Additionally, I may be asked to submit to a post employment physical. If I am a candidate for a position involving operating a commercial vehicle, I hereby acknowledge that I have been made aware that the information I have provided with respect to my previous employers may be used, and my previous employers may be contacted, for the purpose of investigating my background as required by 49 CFR Section 391.23. I understand as a condition of employment, I will be required to show identification which proves my legal right to work in the United States. If employed, I agree to follow the rules, regulations and directives of SurgiSource LLC. However, I understand that my employment can be terminated, with or without cause, and with or without notice, at any time, at the option of either SurgiSource LLC or myself. I understand that I must apply for each open position which I am interested and qualified and that my application will only remain in effect for the opening that I am currently being considered for. I have carefully read and understand the above statement, and hereby consent and agree to these conditions in exchange for SurgiSource LLC's consideration of my application for employment.
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