Previous Work History:
Name of Company: * Earnings: At Hire* - At Termination*Immediate Supervisor: * Business Phone Number: * Type of Business: * Exact Job Title: * Reason for Leaving: * Dates Employed: Date* - Date* Business Address: Street Address* City* State* Zip*Description of Duties: * Do you have any additional work History? Yes No*
Name of Company: * Earnings: At Hire* - At Termination*Immediate Supervisor: * Business Phone Number: * Type of Business: * Exact Job Title: * Reason for Leaving: * Dates Employed: Date* - Date* Business Address: Street Address* City* State* Zip*Description of Duties: *
Certification:I certify that all information I have provided in this 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 understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics, and mode of living. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature of and scope of the investigation. I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employed(except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass an alcohol/drug screening examination: I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required and if permitted by law. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. If this is an at-will state, I understand that this application, verbal statements by management , or subsequent employment does not create an express or implied contract of employment or guarantee employment for any definite period of time. Only the practice manager or owner has the authority to enter into an agreement of employment for any specified period and such agreement must be in writing, signed by such person and the employee. 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 reason and with or without notice. I have read, understood, and by my signature consent to these statements.
Signature Date