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Embed code for: Employmentapplication_001
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APPLICATION FOR EMPLOYMENT
This practice does not discriminate against applicants on the basis of race, sex, color, religion, national origin, age, disability, or veteran status. We are an Equal Opportunity Employer.
Social Security No.:___________________Telephone:_______________________________
Cell: _______________________________E-mail: __________________________________
Are you at least 18 years of age?_________ ___________
If hired, can you provide written evidence that you are authorized to work in the U.S.? _______
Have you served in the military?__________Reserves?_______Branch?_________________
Have you previously worked at this practice, or an affiliate?____________________________
Title of position:________________________Salary Desired:__________________________
How did you hear about this position?_____________________________________________
Date available for work: ________________________________________________________
Type of work desired (i.e., full time, part time, etc.): __________________________________
List special skills, CE coursework, and experience related to this position: ________________
High School:_____________________________Graduation Date:_____________________
Graduate School: __________________________Date:__________Degree:______________
Additional Skills and Training____________________________________________________
WORK HISTORY (Use additional sheets if necessary.)
Duties: _________________________________Reason for leaving:____________________
Duties: _________________________________Reason for leaving:__________________
Is there any information we would need about your name, or use of another name, for us to be able to check your work or education records?
REFERENCES (Please list three. Do not include relatives.)
Name: __________________________________Years Acquainted: __________________
Name: __________________________________Years Acquainted: ___________________
Name: __________________________________Years Acquainted: ____________________
Have you ever been convicted of a felony or criminal offense, including driving under the influence of alcohol or drugs, but excluding traffic violations and parking tickets? Applicants are not obligated to disclose sealed or expunged records of conviction or arrest.
*A conviction record will not necessarily bar you from employment. Each application will be individually considered on its merits.
If yes, please explain:____________________________________________________________
APPLICANT’S STATEMENT (Please read and sign below.)
I understand that this employment application and any other Practice documents are not promises of employment. Should I be employed, I understand that my employment will be on a trial period for ninety (90) days from the date of my hiring. I understand that, if I am employed, either the Practice or myself can terminate my employment with or without cause at any time, including the 90-day trial period. I understand that federal law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment.
I grant permission to the Practice or its duly authorized representatives to contact any persons, companies, schools, or healthcare providers named or referred to in the application (other than my present employer) and I hereby authorize those persons, companies, schools, and healthcare providers to provide my record, reasons for leaving, and all other information they have concerning me to the Practice. I further release all such parties and the Practice from any and all liability claims for damage whatsoever that may result from such contact or information.
The information given by me in this application is true and complete, and I understand that, if the information is found to be false or there is a willful omission, I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.
Signature of applicant:____________________________ Date:_____________________