Employment Application

Name *
Date of Application *
Date of Application
Address *
Phone Number *
Phone Number
Date Available
Date Available
Are you authorized to work in the United States? *
Have you ever worked for this company? *
Have you ever been charged with a felony? *
Please list High School, College, Other. Include Names and Locations of each school, Dates of Attendance, Graduation Status, and Degree.
Please list three professional references. Include their Full Name, Relationship, Company, Phone Number, and Address.
Include the Company's Name, Phone Number, and Address. You will need to provide your Supervisor, Job Title, Stating and Ending Salaries, Responsibilities, Dates of Employment, and Reason for Leaving. Also, CLEARLY STATE whether or not your previous supervisor may be contacted for a reference.
Include Branch, Dates of Service, Rank at Discharge, and Type of Discharge. If your discharge was other than honorable, you will need to explain.
Copy and paste your resume/CV into the box below.
Only fill this section out if you are applying to be a doctor/surgeon/specialist in our practice.
Disclaimer and signature
Please read each paragraph, then check to accept. Upon Completion, enter your name and the date of application at the bottom, then click submit.
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company. *
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company. *
I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation. *
Date of Application *
Date of Application