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Shared Medical Services, Inc.
209 Limestone Pass
Cottage Grove, WI 53527
Tel: 608-839-9050
Fax: 608-839-8950

Name
Last Name
First Name
Middle Name
Other Last Name Used
Social Security Number --
Contact Information
Home Phone Number ()-
Alternative Phone Number ()-
May we contact you confidentially at your alternative number?
E-mail
Date Available To Start
Are you currently under an employment contract?
Are you eligible to work in the U.S.?
If work or educational experience was obtained under another name, please indicate the name
Dates the name was used From:  
  To:       
Have you ever been convicted of a crime other than a traffic violation?
WILL BE CONSIDERED ONLY AS RELATED TO POSITION SOUGHT
If yes, please explain
We have to be prepared to staff our scanners 7 days a week, 24 hours a day. Is there any reason you would not be able to work if your schedule required early morning, evening, or weekend hours?
If yes, please explain
Are you willing to relocate?
Any restrictions?
What is your location preference?
FIRST CHOICE

SECOND CHOICE
Describe any factors or experiences that you believe qualify you for the position you seek or which make you a particularly desirable applicant
What are your salary expectations?
How did you find out about the job?  Newspaper 
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Residences

Please list all addresses where you have lived in the last three (3) years.

Please list most recent or present address first.
Current From  
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Address
Address 2
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Zip
Previous From   
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Address
Address 2
City
State
Zip
Previous From   
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Address
Address 2
City
State
Zip
Education
High School Name
Address
City
State
Zip
GPA
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
What courses did you like most and why?
What courses did you like the least and why?
Describe any other educational or training programs you have completed that you believe are relevant to the position you seek
Foreign Language
I am able to speak
I am able to speak
Employment History

Please provide information on all employment for the most recent three (3) years.

Please list most recent or present employment first.
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From:  
  To:       
Type of Business
Position
Immediate Supervisor
Ending Compensation $ 
Briefly describe your duties and responsibilities
Reason(s) for Leaving
May we contact this employer?
Were you subject to the FMCSR's while employed?
Was your job designated as a safety-sensitive function in any DOT-regulated modes, subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From:  
  To:       
Type of Business
Position
Immediate Supervisor
Ending Compensation $ 
Briefly describe your duties and responsibilities
Reason(s) for Leaving
Were you subject to the FMCSR's while employed?
Was your job designated as a safety-sensitive function in any DOT-regulated modes, subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From: