New hire applicants will be subjected to a new hire physical which will also require a drug screen and the hiring will not go any further until the results are submitted back to our office from the participating clinic and if hired the applicant will have to participate in random drug screens and go through a new hire orientation.

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, religion, creed, color, gender, national origin, citizenship status, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

INDICATE POSITION(S) DESIRED:

HOW DID YOU HEAR ABOUT US? :

If other, please specify:

Are you under 18 years of age? Yes No

Have you ever filled an application with us before? Yes No

If yes, please indicate date:

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this Country because of Visa of Immmigration Status?

Proof of citizenship or immigration status will be required upon employment Yes No

On what date would you be able to start work?

Are you currently on "lay-off" status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Have you been convicted of a felony in any jurisdiction? Yes No

If yes, please explain:

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THE FOLLOWING QUESTIONS UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING

Are you capable of performing in a reasonable manner, with or without a reasonable Accommodation, the activities in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation is attached? Yes No

Education

	Name and Address of School	Course of Study	Years Completed	Diploma Degree
High School
Undergraduate College
Graduate College
Other (Specify)

OPTIONAL

If you would like to be considered for a position which requires proficiency in another language, please indicate by checking the box and indicating the language(s) in which you are fluent.

Yes Fluent in:

Specialized Skills & Qualifications:

Check all which apply:

Please List current Professional Certifications, registrations, and licenses. Please include state of issuance, and expiration dates if applicable.

Describe any specialized training, apprenticeships, skills, or experience with special population:

Describe any job-related training received in the United States military:

Former Employers

(List below your last four employers, starting with the most recent one first.)

	Date(M/Y):	Name & Address of Employer:	Salary:	Position:	Duties:	Reason for Leaving:
From:
To:
From:
To:
From:
To:
From:
To:

References

(Please include at least two supervisors)

APPLICANT'S STATEMENT

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the release any information regarding my employment. I also authorize to check my background for any criminal record.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of at will employment in certain jurisdictions and that relationship may or may not be changed by any written document or by conduct unless such change is specifically acknowledge in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate discharge from employment from our organization. I understand that I am required to abide by all rules and regulation set forth by the employer.

Signature of Applicant:

Employment