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Personal

Last Name: [REQUIRED]
 
First Name: [REQUIRED]
 
Initial:
Social Security #:
- -
Permanent Address: [REQUIRED]
 
City: [REQUIRED]
 
State: [REQUIRED]
 
Zip: [REQUIRED]
 
Contact Number: [REQUIRED]
 
Are you less than 18 years of age ?  [REQUIRED]

 
Other name(s) under which you have previously been employed:
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country ? [REQUIRED]

 
Email Address: [REQUIRED]
 
Have you ever been employed by this organization before ?  [REQUIRED]

 
If yes, give dates of employment:
Have you ever applied to this organization before? [REQUIRED]

 
If yes, give date and position applied for:
How were you referred to our organization?
Names of relatives employed in this organization:

Employment Interests


Position Name: [REQUIRED]
 
Position Number: [REQUIRED]
 
Position Name:
Position Number:
Position Name:
Position Number:
Position Name:
Position Number:
Date Available: [REQUIRED]
 
Salary Expected:
Type of employment you are seeking: For how long?
Shifts you can work:

Indicate applicable work skills:

TypingWPM [REQUIRED]  
10-keySPM [REQUIRED]  
Computer Systems/Software: [REQUIRED]
 
Other job related skills: [REQUIRED]
 

Education/U.S. Military Service

High School

Name and address of School: [REQUIRED]
 
Major: [REQUIRED]
 
No. of years completed: [REQUIRED]
 
Did you graduate: [REQUIRED]
 
Degrees/Diplomas: [REQUIRED]
 

College

Name and address of School:
Major:
No. of years completed:
Did you graduate:
Degrees/Diplomas:

Other

Name and address of School:
Major:
No. of years completed:
Did you graduate:
Degrees/Diplomas:
Are you taking any educational courses presently? [REQUIRED]
If yes, what and where:
 
Some of our patients do not speak English. Do you speak, read or write any foreign languages or fluently use sign language? If so, which ones?
Do not answer if you feel it would reveal ethnic background.
Speak:

Read:

Write:
Have you ever served in the U.S. Armed Forces? [REQUIRED]
 
U.S. military duties & special training relevant to position you are seeking:
Rank held at discharge:

Professional Licenses/Certifications

License/Certification 1

Type:
State:
Expiration Date:
Registration Number:

License/Certification 2

Type:
State:
Expiration Date:
Registration Number:

License/Certification 3

Type:
State:
Expiration Date:
Registration Number:

License/Certification 4

Type:
State:
Expiration Date:
Registration Number:

Volunteer / Internship / Externship

Volunteer / Internship / Externship 1

Name of Organization:
Dates:
Duties:

Volunteer / Internship / Externship 2

Name:
Dates:
Duties:

Volunteer / Internship / Externship 3

Name:
Dates:
Duties:

Employment History

EMPLOYMENT HISTORY - LIST ALL EMPLOYERS BEGINNING WITH THE MOST RECENT

GIVE EMPLOYMENT RECORD AS COMPLETELY AS POSSIBLE, AND INDICATE DATES AND COMMENTS ON EACH PERIOD. FOR ADDITIONAL EMPLOYMENT HISTORY, PLEASE ATTACH A RESUME.

Employer 1

Company Name: [REQUIRED]
 
City, State: [REQUIRED]
 
Telephone: [REQUIRED]
 
Job Title: [REQUIRED]
 
Supervisor's Name/Title: [REQUIRED]
 
Type of Business: [REQUIRED]
 
Description of Duties: [REQUIRED]
 
Dates Employed (month/year): [REQUIRED]
From:     To:  
Reason for leaving: [REQUIRED]
 
May we contact this employer? [REQUIRED]
 

Employer 2

Company Name: [REQUIRED]
 
City, State: [REQUIRED]
 
Telephone: [REQUIRED]
 
Job Title: [REQUIRED]
 
Supervisor's Name/Title: [REQUIRED]
 
Type of Business: [REQUIRED]
 
Description of Duties: [REQUIRED]
 
Dates Employed (month/year): [REQUIRED]
From:     To:  
Reason for leaving: [REQUIRED]
 
May we contact this employer? [REQUIRED]
 

Employer 3

Company Name: [REQUIRED]
 
City, State: [REQUIRED]
 
Telephone: [REQUIRED]
 
Job Title: [REQUIRED]
 
Supervisor's Name/Title: [REQUIRED]
 
Type of Business: [REQUIRED]
 
Description of Duties: [REQUIRED]
 
Dates Employed (month/year): [REQUIRED]
From:     To:  
Reason for leaving: [REQUIRED]
 
May we contact this employer? [REQUIRED]
 
Make any comments you feel are pertinent to your application:
NOTE: All text should be entered as a single paragraph, do not use ENTER key


Upload Your Resume (optional):
 


Acknowledgement

PLEASE READ CAREFULLY. TYPE YOUR INITIALS NEXT TO EACH PARAGRAPH AND TYPE YOUR NAME BELOW.

  [REQUIRED]
1. I understand that as a condition of employment I may be required at any time to undergo physical examinations (including blood, urine, breath and other laboratory tests for drugs or alcohol or other legitimate reasons) concerning my ability to perform any job, for which I may be involved, safely or efficiently. If I am required to undergo any examinations or tests, I understand that to the extent such is permissible under the Health Insurance Portability and Accountability Act of 1996 (commonly referred to as HIPPA) as well as any other applicable State or Federal law, I will be required to authorize all such health care providers who examine or test me to disclose to the company to which I am now applying for employment or promotion, all medical information reasonably necessary to allow them to determine if I can safely and reasonably perform the job duties and responsibilities involved. I further understand that if I refuse to consent to such examinations or tests, or to authorize the release of the medical information resulting therefrom, in compliance with this provision, I may be subject to disciplinary action, up to and including refusal to be hired and/or termination of my employment if actually hired.
  [REQUIRED]
2. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment. I hereby authorize the employer to whom I am now applying to investigate my references, work record, credit record if applicable, education and other matters relating to my suitability for employment and, further, authorize my former employers to disclose to this company any and all letters, reports and other information related to my work records. To the extent, if at all, I have a right to waive the right to notice of such disclosures, I hereby do so and furthermore, to the extent I have a right to release this company, my former employers and all other persons, corporations, partnerships and associates from any and all claims, demands or liabilities arising out of, or in any way related to such investigation or disclosure, I hereby do so.
  [REQUIRED]
3. I understand this employment application is not to be construed as a guarantee of employment for a specific time. I further understand that my employment with the organization does not constitute any form of contract, implied or expressed. I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without cause, at the option of either myself or the company to which I am now applying for either employment and/or promotion, and that no promises or representations contrary to the foregoing are binding on the company. My continued employment is dependent on satisfactory performance and the continued need for my services as determined solely by the company.
  [REQUIRED]
4. I understand that proof of identity and right to work in the United States will be required within first three days of employment with the company for which I am now applying. This information, I understand, is required for continued employment.
  [REQUIRED]
5. I have reviewed the requirements of this role and understand that this role may require me to be fully vaccinated for COVID-19 and to provide proof of vaccination prior to beginning employment. I agree to abide by the vaccination requirement for this role.
  [REQUIRED]
6. I hereby acknowledge and agree that upon cessation of my employment, my final paycheck will immediately be provided to me or by mail to my last known mailing address.
  [REQUIRED]
7. I hereby acknowledge and agree that I am waiving the right to receive a copy of any public record obtained while doing any type of background check on myself.
  [REQUIRED]
8. I hereby acknowledge that I have read all of the above statements and that I understand them.
Applicant's Name: [REQUIRED]
By typing in your name below and submitting this form, you are verifying the information is correct.