* Required Information

Educational Background

High School


Graduate School

Vocational Training/Other

Employment Experience

Place an X by any employer(s) you do not want us to contact. List your most recent employer first.

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time. I also understand and agree that the terms and condition of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. My employment is contingent upon background and drug screening results.

Background Check Authorization

In an effort to protect the residents/patients of our Clients’, Focused, Inc. dba First Call Medical Solutions requires a background screening for all employees. Your employment with Focused, Inc. dba First Call Medical Solutions is contingent upon the results of this Background Check. Failure to comply may result in a denial of your employment or contract.

Current Address Since

Previous Address From

A “No” answer to all questions does not guarantee employment.

I have personally completed and reviewed this form and affirm that the information is true and correct as of today’s date. I hereby authorize Focused, Inc. dba First Call Medical Solutions and its’ designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment purposes. I understand that the scope of the consumer report/investigative report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including SSA and law enforcement) to divulge any and all information, verbal or written, pertaining to me, to Focused, Inc. dba First Call Medical Solutions or its’ agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I hereby release Focused, Inc. dba First Call Medical Solutions and its’ agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

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