Application2018-09-14T13:30:06+00:00

Employment Application

I'm available to work*
Full-TimePart-Time

Shift preference*
First (8am - 4pm)Second (4pm - 12am)Third (12am - 8am)

Where did you hear about Midstates?
NewspaperRadioCurrent EmployeeOnlineOther

Are you over 18 years of age?
YesNo

Have you ever been employed with this company?
YesNo

Are you employed now?
YesNo

May we contact your present employer?
YesNo

Are you prevented from lawfully becoming employed in the country because of Visa or Immigration status?
YesNo

Do you have a valid drivers license?
YesNo

Have you been convicted of a crime? (Please note that a "Yes" answer will not bar you from consideration for employment.)
YesNo

Education

Did you graduate?
YesNo

Did you graduate?
YesNo

Employment Experience 1

Employment Experience 2

Employment Experience 3

Reference 1

Reference 2

Reference 3

I hereby certify that all information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I authorize Midstates Group to verify the accuracy and information provided. I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that submission of an application does not guarantee employment. If hired, I will be employed at will; I understand that this means that either I or the employer is free to terminate the employment relationship at any time with our without cause or prior notice. I understand that no representative of the company, other than the CEO, has any authority to enter into an agreement for employment for any specified period of time or, in any way, to modify the at-will nature of the employment relationship.

I understand that if I am offered employment, it could result in a pre-employment drug screening and background check at the expense of Midstates Group and that this is a condition of employment.

I understand that should and employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Midstates Group.

By entering my name below I acknowledge that I have read, understood and agree to the above statements.


This application is valid for ninety (90) days from the date signed. If you would like to be considered for job openings more than ninety (90) days from the date signed, please submit a new application.