* Indicates Required Information
APPLICATION FOR EMPLOYMENT
It is our policy to provide equal employment opportunities to all qualified persons without regard to race, color, religion, sex, national origin, ancestry, age, disability or any other basis protected by state or federal law.
 
Personal Information
 
Social Security Number:* Date:*
 
Name:* Previous Name(s):
  Last First Middle  
 
Address:*
  Street City State Zip
 
Phone Number:* Alternate or Work Phone:
 
Referred By:
If Employee Referral or Other:
 
Are you 18 years or older?* Yes No
 
Driver's Licence Number: State:
 
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?* Yes No
 
Have you ever been convicted of any crime, including misdemeanors and felonies?* Yes No
 
If yes, please state the nature of the offense(s) and the date of the conviction(s).
 
NOTE: Answering "yes" to the above question does not constitute an automatic bar from employment. Factors such as the date of the conviction, seriousness and nature of the conviction, and position applied for will be considered.

Employment Desired
 
Position:* Date you can start:  Salary desired: 
 
Are you available to work: Full-Time Part-Time Temporary
 
Can you perform the essential functions of the job(s) for which you are applying, as you understand them, with or without reasonable accommodation?*
 
Have you ever been employed by NMC before?* Yes No If yes, when: 
 
Have you filed an application with this company before?* Yes No When? Where?
 
Are you employed now?* Yes No       If so, may we contact your present employer? Yes No

Employment History Please describe your entire employment history starting with your current or last job. Include military assignments if applicable and list any periods of unemployment or self-employment.
 
From: / / To:  / / Employer:  Supervisor: 
Employer Address:    Telephone Number: 
Position:   Wage/Salary: 
Principal Job Duty:
Reason for Leaving:
 
From: / / To:  / / Employer:  Supervisor: 
Employer Address:    Telephone Number: 
Position:   Wage/Salary: 
Principal Job Duty:
Reason for Leaving:
 
From: / / To:  / / Employer:  Supervisor: 
Employer Address:    Telephone Number: 
Position:   Wage/Salary: 
Principal Job Duty:
Reason for Leaving:
 
From: / / To:  / / Employer:  Supervisor: 
Employer Address:    Telephone Number: 
Position:   Wage/Salary: 
Principal Job Duty:
Reason for Leaving:

Education
 
  Name & Location* Number of years completed* Did you graduate?* Subject(s) studied & Degree(s) received
High School  Yes No
College  Yes No
Other  Yes No

Additional Information
 
Please list any additional information you would like us to consider (i.e. specialized skills, certifications, etc.):
 
Have you ever been discharged from a job?* Yes No
If yes, please explain why:
 
May we telephone you to follow up on this application at home?* Yes No
If yes, what is the best time to call?
 
May we telephone you to follow up on this application at work?* Yes No
If yes, what is the best time to call?
If yes, what is your business telephone number?

Authorizations
 
Pre-Employment Physical: I understand that NMC requires applicants to participate in a pre-employment physical examination upon receiving a conditional offer of employment. NMC pays all costs involved with the examination. I understand and acknowledge that any offer of employment may be conditioned upon my successful completion of this examination.

Drug and Alcohol Testing: I understand that NMC may require all applicants to undergo pre-employment drug and alcohol testing after receiving a conditional offer of employment. Applicants will receive additional information about drug and alcohol testing and be required to signed an authorization regarding the same upon receiving a conditional offer of employment. I understand and acknowledge that any offer of employment will be conditioned upon my successful completion of the drug and alcohol test.

Acknowledgment
 
I hereby certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I release all parties and persons that may provide information to NMC from any and all liability and from any damages that may result from furnishing information to NMC as well as from the use or disclosure of this information by NMC or any of its agents, employees or representatives. I understand that any representation, falsification or material omission of information on this application, in a related employment resumé or in a personal interview may result in my failure to receive an offer or, if I am hired, in the termination of my employment.
 
Applicant Name* Date*

Authorization And Release
 
In consideration of NMC's evaluation of my suitability for employment, I authorize the Company to perform all checks of my credentials as allowed by law including, but not limited to Motor Vehicle Report discussions with: supervisors, co-workers, friends, business associates, former employers or other individuals that the Company, in its sole discretion, believes may have relevant information regarding my suitability for employment.

I agree not to assert any claims or causes of action of any kind against the Company, its agents, its employees, or any individual contacted by the Company, arising out of the Company’s investigation. I further release and forever discharge the Company, its agents, its employees, and the individuals and companies contacted by the Company as part of its investigation, from any and all claims, demands, damages, actions, causes of action, or suits of any kind or nature whatsoever arising from the Company’s investigation of my credentials. I acknowledge that the Company has made no representations of any kind as to whether employment will be offered at the conclusion if its investigation.
 
Applicant Name* Date*

EMPLOYMENT AT WILL
 
I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between NMC and me for either employment or the provision of any benefits. I further understand that if an employment relationship subsequently is established, I will have the right to terminate my employment at any time and NMC will have a similar right.
* Indicates Required Information