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Application for Employment

An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.


Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Add additional details in the notes at the bottom if you do not have enough room on this application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.
 

Position

 Full-Time  Part-Time  Temporary

Personal

Last
First
Middle
House Number and Street
City
State
Zip
Daytime
Evening
(no dashes)
 Yes  No
 Yes  No

 Yes  No
 Yes  No
 Yes  No
If yes, give details:
Note: Answering "Yes" does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.
 Yes  No
If yes, please list & give relationship:
 Yes  No
Driver's License Number
Class of License
 Yes  No
If yes, give details:

Education

School Name/Location Course of Study Years Completed Graduated
Major
Degree
Major
Degree

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
Dates:
to
Salary

 Yes  No
 Yes  No
 Yes  No
 Yes  No

References

Give three references, not relatives or former employers.

Please read each statement carefully before signing
I certify that all information provided in the employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving record and criminal history. I authorize any person, school, currand former employer, consumer reporting agency, and any other organization or agency to provide information relevant to such investigation and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so. I understand that I have the right to make a written request within a reasonable period of time for complete disclosure of the nature and scope of any investigation. I further authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the job for which I am being considered or any future job in the event that I am hired.

I understand that compliance with the Company's Policies & Procedures is a condition of my employment.

I understand that I must successfully pass both drug and criminal background screenings. I hereby consent to these screenings as a condition of my employment.

I understand that in accordance with the Collom & Carney Compliance Plan, the clinic will conduct appropriate screening to verify that I have not had any sanctions imposed on me by Federal or State Law Enforcement, Regulatory, or licensing agency for either conduct or performance based action.

I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time with or without cause and with or without notice.

I have read, understand, and by my signature consent to these statements.
Optional
This application for employment will remain active for 90 days.