Have you ever applied to / worked for (Regaliz Medicare Ltd.) before?

Do you have any friends, relatives, or acquaintances working for [Our Company]?

Have you been convicted of or pleaded no contest to a crime within the last five years?

If yes, please describe the crime - state the nature of the crime(s), when and where convicted, and the disposition (final settlement) of the case:


High School :

College / University :

Employment History :

You should be prepared to detail each position for the past five years and account for any gaps in employment during that period.

Are you currently employed?


I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment if I am hired. I authorize the verification of all information listed above.