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EMPLOYMENT APPLICATION

Our Practice is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender identity, marital status, natural origin, disability or handicap, veteran status.

PERSONAL DATA

Name*
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Address
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Are you over 18 years old?

POSITION INFORMATION

Applying for
Are you authorized to work in the United States on an unrestricted basis?
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment)

EDUCATION

Do you have a High School Diploma or GED?
High School Information
School Name
Address
College and or Vocational School
School Name
Address
 

PROFESSIONAL LICENSE OR MEMBERSHIP

SPECIAL SKILLS

List any special skills or experiences that you feel would help you in the position that you are applying for (leadership, organization/teams, etc.)

WORK HISTORY

Start with you present or most recent employment and work back. (INCLUDE PAID AND UNPAID POSITIONS) If any employment was under a different name, please indicate name.
Work history Information
Company Name
Start Date
End Date
Job Title
Phone Number
Address
Supervisor Name
Duties
Reason for leaving
Starting Salary
Ending Salary
May we contact this Employer (Y/N)
 

REFERNCES

References Information
Name
Telephone
Address
Relationship
 

Résumé

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Max. file size: 256 MB.

    APPLICANT’S CERTIFICATION AND AGREEMENT:

    I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize the practice to verify their accuracy and to obtain reference information on my work performance. I hereby release the practice from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

    I understand that, if employed, falsified statements of any kind or omission of facts called for on this application shall be considered sufficient basis for dismissal.

    I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the practice. However, I further understand that neither policy, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

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